the oireachtas (joint irish houses of parliament) draft
TRANSCRIPT
DRAFT
The Oireachtas(Joint Irish Houses of Parliament)
Draft report on Water Fluoridation inIreland
John Gormley
11th January 2007
1 Introductory Note
Extracted from: Irish Times, Thursday 15th March 2007. The publication of a reporton fluoridation to the Oireachtas Health and Children Committee written by GreenParty Dublin South East TD, John Gormley, is expected to be strongly opposed bysome other committee members in the coming weeks. Rejecting the Green’s oppositionto fluoridation, the Fianna Fail TD, Jimmy Devins, vice-chair of the committee, saidwater fluoridation “is in the interests of public health and should not be discontinued.All the evidence available has indicated to us that water fluoridation is in the interestsof public health. It prevents dental caries and has no negative side effects aside from aslight staining of teeth in a small number of cases which can be easily treatable.” MrDevins said he would oppose Mr Gormley’s report getting the official sanction of thecommittee.
Here is the report which was suppressed by certain committee members. This reportwas never put to the vote.
Contents
1 Introductory Note 1
2 Executive Summary 3
3 Conclusions 5
4 Recommendations 7
1
DRAFT
5 Historical Background 8
5.1 Water Fluoridation in Ireland . . . . . . . . . . . . . . . . . . . . . . . . . 8
5.2 The High Court Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
5.3 The Fluoridation Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
5.4 Aftermath of the Fluoridation Forum . . . . . . . . . . . . . . . . . . . . . 20
6 Water Fluoridation and Dental Caries 21
6.1 What is Dental Caries, and How Can Fluoride Help? . . . . . . . . . . . . 22
6.2 Water Fluoridation and Dental Caries in Ireland . . . . . . . . . . . . . . 22
6.3 The Reduction of Dental Caries in Developed Countries . . . . . . . . . . 24
6.4 Water Fluoridation and a High Sugar Diet . . . . . . . . . . . . . . . . . . 29
6.5 A Comparison in DMFT between Ireland and Scotland . . . . . . . . . . 31
6.6 The York Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
6.7 Studies in Ireland Assessing the Difference in Decay levels . . . . . . . . . 34
6.8 Decay Free Children in Fluoridated and Non-fluoridated Areas. . . . . . . 42
6.9 International Studies Show Little Benefit from Water Fluoridation . . . . 43
6.10 Dental Decay in Adults and the Theory of ‘Delayed Eruption’ . . . . . . . 47
6.11 What would happen if we stopped water fluoridation in Ireland? . . . . . 47
6.11.1 Former East Germany . . . . . . . . . . . . . . . . . . . . . . . . . 48
6.11.2 Finland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.11.3 Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.11.4 Michigan US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.11.5 Cuba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.12 Who Benefits Most from Water Fluoridation and possible alternatives? . . 50
6.13 Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
7 Health Effects 55
7.1 The Legitimate Scientific Controversy . . . . . . . . . . . . . . . . . . . . 55
7.2 The York Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
7.3 The “Legitimate Scientific Controversy” . . . . . . . . . . . . . . . . . . . 56
7.4 Dental Fluorosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
7.5 Signs of Dental Fluorosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
7.6 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.7 Dental Fluorosis Levels in Ireland . . . . . . . . . . . . . . . . . . . . . . . 58
7.8 Dental Fluorosis Levels according to the York Review . . . . . . . . . . . 59
7.9 Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
7.10 Total Fluoride Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
7.11 Risk from Systemic Fluorides. . . . . . . . . . . . . . . . . . . . . . . . . . 61
7.12 Risk from Fluoride Supplements . . . . . . . . . . . . . . . . . . . . . . . 61
7.13 Risk from Topical Fluorides . . . . . . . . . . . . . . . . . . . . . . . . . . 62
7.14 Implications of Dental Fluorosis . . . . . . . . . . . . . . . . . . . . . . . . 62
7.15 Fluoride and Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
7.16 Hip fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
7.17 Skeletal fluorosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
2
DRAFT
7.18 Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 677.19 Bone Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687.20 Uterine Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697.21 Fluoride and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697.22 Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707.23 Silico-fluorides and Lead levels in Children’s blood . . . . . . . . . . . . . 717.24 The Pineal Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717.25 Other Related Health Implications . . . . . . . . . . . . . . . . . . . . . . 72
7.25.1 Down’s syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727.25.2 Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727.25.3 Allergic responses . . . . . . . . . . . . . . . . . . . . . . . . . . . 727.25.4 Infant Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737.25.5 The Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . 737.25.6 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747.25.7 Mutagenicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
7.26 US National Academy of Sciences . . . . . . . . . . . . . . . . . . . . . . . 75
8 Irish Dentists Opposing Fluoridation 848.1 I.D.O.F. Policy on Water Fluoridation . . . . . . . . . . . . . . . . . . . . 84
8.1.1 Infringement of our human rights . . . . . . . . . . . . . . . . . . . 858.1.2 Dental Fluorosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858.1.3 Health damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858.1.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
9 Glossary 88
10 Bibliography 88
December 2006
2 Executive Summary
I am very pleased to present my Report on Water Fluoridation to the Joint OireachtasCommittee on Health and Children. I was appointed first to undertake this work in1999 during the last Dail. Unfortunately, I was advised by the Committee Chairman tointerrupt my work when the then Minister for Health and Children, Micheal Martin, setup the Fluoridation Forum to conduct a similar investigation into the action of fluoride.Following the completion of the Forum Report, the Health Committee recommenced itsown investigation. Given that sufficient time has now elapsed since the publication of theForum Report and that not a single recommendation out of 33 has been implemented,it is timely to publish our deliberations on the subject.
Having agreed to become the rapporteur, I quickly discovered that I faced a complexand mammoth task. Not only did I have to analyse the testimony of those who appearedbefore the Committee, I also had to wade through the often contradictory scientificevidence and the endless archive material.
3
DRAFT
I have tried to distill the essential elements of my research into this report. As well aslooking at why water fluoridation was introduced into this country, the report seeks toanswer two fundamental questions — (1) how effective is water fluoridation in fightingtooth decay? (2) what are the side effects of water fluoridation?Those who came before the committee had often diametrically opposed views on the
subject. There is no doubting the sincerity and dedication of both sides in this debate.It is worth noting however, that whereas there was almost unanimity in the dentalcommunity when water fluoridation was introduced as to its effectiveness, there are nowclear differences of opinion among dentists on the subject. One only has to contrast thetestimony of Dr. O’Mullane and Dr. Clarkson with Dr. MacAuley and Dr. Limeback tounderstand how greatly views diverge on water fluoridation. But there is some commonground. And it’s worth reflecting on these points of agreement at the very outset. Whenfluoride was first introduced it was thought generally to act systemically i.e. it had tobe ingested. We now know it acts topically i.e. in the mouth and on the surface of thetooth. We also know that there are increased sources of fluoride now compared to fiftyyears ago. All sides admit - and the evidence points to - a huge increase in the incidenceof fluorosis, a condition which indicates an excess of fluoride. Both sides also took theview that fluoride in toothpaste did reduce the rate of dental caries. They also agreethat children who use fluoride toothpaste require supervision and proper instruction.The crucial question for the committee was whether the perceived benefits of water
fluoridation outweighed the negative side effects. The contribution of international ex-pert, Dr. Hardy Limeback was persuasive in this regard when he commented that usingthe most authoritative international data, the risk of fluorosis far outweighed the benefitsof fluoride. Dr. Limeback was also very clear in his recommendation that fluoridatedwater should not be used to bottle feed babies. Indeed, his advice seemed to have beenaccepted by the Food Safety Authority until it changed its mind in circumstances thathave not been explained to the satisfaction of the committee. The committee has alsonoted the latest advice of the American Dental Association which states:
“If using a product that needs to be reconstituted, parents and caregiversshould consider using water that has no or low levels of fluoride”. (ADA 9thNovember 2006)
Given that it is extremely impractical for mothers who are bottle feeding to sourcenon-fluoridated water supplies and that fluorosis rates continue to rise, our central rec-ommendation - based on the precautionary principle - is that the practice of waterfluoridation should end immediately. All of the available evidence suggests that not onlywill this lead to a marked reduction in fluorosis but that there would not be a significantrise in dental caries.The evidence presented by Dr O’Mullane showed that Ireland had a very serious dental
health problem in the 1950s and early 60s. All of the available historical records confirmthis to be the case. They also show that Ireland had a real shortage of dentists atthe time. The committee fully appreciates why a prophylactic measure such as waterfluoridation seemed like a sensible approach at the time. However, we have had to baseour conclusions and recommendations on all of the data now available to us. Quantifying
4
DRAFT
the effectiveness of fluoridation was our most difficult task. In our view, the mostaccurate measurement of this is contained in the York Review, undoubtedly, the mostcomprehensive study ever to be carried out on water fluoridation. Similarly, we havereferred to York Review in quantifying fluorosis rates.A key recommendation of the Fluoridation Forum was the reduction in the level of
fluoride in our water supplies. Significantly, this recommendation has not been imple-mented, and even if the fluoride levels in the water were slightly reduced, we could notrecommend that this water be used to bottle feed babies.The Ireland of 2006 is a very different place with very different standards of general
and oral hygiene. We are a modern European state with dental caries rates, equal to,and sometimes below other EU states which do not fluoridate their water supplies. Wedo, however, continue to consume too much confectionery, and our snacking habits areleading to continued dental caries problems as well as higher rates of obesity. The De-partment for Health and Children should tackle this problem by concentrating its effortson education in relation to better oral hygiene, banning junk food vending machines andusing fiscal means to change these poor eating habits.If our recommendations are implemented we are convinced that not only will we see
a reduction in fluorosis rates but that there will also be a drop in dental caries rates.
3 Conclusions
1. The rates of dental decay and the lack of dentists justified the introduction of aprophylactic measure such as water fluoridation.
2. Those who advocated water fluoridation were motivated by concern about theserious decline in dental health standards.
3. We believe that basic health and hygiene habits in Irish society have changeddramatically in the intervening period.
4. We note that dental health has improved to the same degree in countries wherethere is no water fluoridation.
5. The Department of Health’s assessment of the overwhelming benefits of waterfluoridation is not justified.
6. While positive aspects of fluoridation have been over-stated, the growing negativeimpact has not been properly recognised. The Committee views the officiallyreported sevenfold increase in fluorosis since 1984, as completely unacceptable,requiring immediate action.
7. The Committee is disappointed and alarmed that no general health studies, asprovided for in S.6 of the 1960 Fluoridation Act have ever been carried out, par-ticularly considering that four in ten 15 year olds are now affected by fluorosis.By disregarding this provision of the Act, the Department of Health has left itselfliable for the harmful effects of fluoridation of Irish drinking water.
5
DRAFT
8. It is the view of the committee that the Department of Health has failed to offer acoherent scientific justification for continuing the policy of water fluoridation andhas notably failed to deal with Dr Connett’s 50 Reasons to oppose fluoridationeither in the Fluoridation Forum or since.
9. Despite emphasising the expertise of its membership, the Fluoridation Forum failedto apply key principles of toxicology, for example the toxic dosage for Irish children.Another failure was to overlook the synergistic effects of fluoride chemicals withother substances (e.g. aluminium) that are ever-present in many Irish drinkingwater supplies.
10. The Committee notes that the recommendation of FSAI advising against the useof fluoridated water for the bottle feeding of babies was changed subsequentlyfollowing representations from a minority of members in 2001.
11. The Committee believes that the manner this was done was both irregular andsuspect and represented a “process mess”. The replies given to the former Chairby Dr Wayne Anderson in this regard were unsatisfactory. The Committee notes asimilar change in advice on using non-fluoridated water in infant formula by ProfJohn Clarkson.
12. The committee notes that the vast of majority of those on the Forum for fluorida-tion had records of being strongly in favour of water fluoridation.
13. It is clear and, indeed, accepted by both the pro- and anti-fluoridation sides thatthe action of fluoride is topical and not systemic.
14. We note that of the 33 recommendations of the Fluoride forum, not one has beenimplemented to date.
15. We believe on the basis of the international studies there would be no long-termincrease in dental decay if fluoride were not added to Irish drinking water.
16. There is no evidence to suggest that Irish people are fluoride deficient, in fact, theevidence at hand suggests that we have too much fluoride in our systems.
17. On the basis of the available archive material the Committee believes that theoriginal Fluorine consultative council did not approach its task with an open mind.It would appear to have had a very strong pro water fluoridation bias.
18. We are disappointed that only the minutes of one of the meetings of the Fluorineconsultative Council survive, the others having been destroyed in a flood.
19. It is now accepted by all sides that the sources of fluoride in our diet have increaseddramatically since the introduction of water fluoridation.
20. The Committee believes that fluoride toothpastes have contributed to a decline indental caries in this country and other states.
6
DRAFT
21. Fluoride toothpastes should carry a warning about the dangers of children swal-lowing fluoride toothpastes, and children properly supervised when brushing theirteeth using fluoride toothpaste.
22. The increase in membership of Irish Dentists Opposing Fluoridation from singlefigures when the Forum reported, to over 120 dental practitioners today reflectsthe growing professional opposition to the policy.
23. There is sufficient scientific evidence in relation to health effects - albeit contra-dictory - to justify the application of the precautionary principle. We also notethe latest advice from the American Dental Association which advises parents tochoose non-fluoridated water for the bottle feeding babies.
24. We note that the fluoridating agent hydrofluorosalicic acid has not been sanctionedby the Irish Medicines Board.
4 Recommendations
1. Fluoridated water should not be used to bottle feed babies;
2. Given the impracticality of sourcing non-fluoridated water for the bottle feedingof babies, the committee – on the basis of the precautionary principle – believesthe practice of water fluoridation should cease immediately;
3. The savings accruing from the policy change must be assessed in each HSE region.They should be ring-fenced before being re-allocated to educational programmesaimed at the socially deprived, in line with best practice in other European coun-tries;
4. Independent research into general health effects should be undertaken in order toassess the full impact of lifetime fluoride exposure in the population. Particularattention should be given to effects on infants and children of exposure to fluoridefrom all sources;
5. The Minister for Health should not permit indiscriminate medication measures totreat the whole population via water or food because of the inability to controldosage and monitor individual reaction, evidenced by the forty year experience ofwater fluoridation;
6. The Government should undertake a major educational programme to encouragehealthy eating in order to tackle the twin problems of dental caries and obesity;
7. More public dentists need to be employed and more regular check ups encouraged;
8. Parents should be given advice about teeth brushing and the use of fluoridatedtoothpaste. Along with imaginative education programmes on regular tooth brush-ing, existing nutritional programmes already underway should continue to target
7
DRAFT
sugary diets of children from 5 yr olds to 15 yr olds. Special emphasis should belaid on initiatives that target the socially disadvantaged where dental decay linkedto poor diet is most prevalent; and
9. Fluoride toothpastes should carry warnings similar to those in the United Statesabout the dangers of swallowing fluoride toothpaste.
5 Historical Background
5.1 Water Fluoridation in Ireland
Much of the information contained in this account is taken from Paul Beirne’s Ireland’smandatory fluoridation policy: an historical analysis of the policy process. Other sourcesinclude Dail debates and the National Archives.The Department for Health was headed by five different Ministers between 1948 and
1960. During that period, however, the senior civil servants in the Department remainedunchanged. The Secretary of the Department, Padraig O’Cinneide and the AssistantSecretary, Paddy Murray played pivotal roles in the water fluoridation policy-makingprocess.The public dental services had never been a major priority for the Department, but
this changed in July 1951 when the Minister for Health, Dr Jim Ryan (Fianna Fail), ap-pointed a dental consultative council to advise him on “the improvement and extensionof the dental services at present provided by Local Authorities”.[2] The Council notedthat there were 624 names on the dental register in Ireland. Of these, only 560 dentistswere in active practice, which gave a dentist to population ratio of 1:5,300. The Councilnoted that this dentist-to-population ratio did not compare favourably with other coun-tries – Norway 1:1,600, Sweden 1: 2,300, Denmark 1: 2,300, Scotland 1: 4,100, England& Wales 1: 4,600.The Council did express the view that the dentist/population ratio in other countries
might not be necessarily fully comparable with this country, as there were
“too many unknown factors involved, such as, the relative incidence of dentalcaries and the extent to which persons would seek treatment”.[2]
Nevertheless, they recommended that 325 dentists would be required in the Local Au-thority Dental Services to cater for four priority groups:
1. Pupils of National Schools;
2. Children attending Welfare Clinics and women in respect of motherhood;
3. Adolescent 14-19 yrs. Group 3[2];
4. Adults eligible for treatment under the Public Assistance Act 1939.[2]
The first investigation into dental caries in Ireland was undertaken in 1952 by the MedicalResearch Council of Ireland at the request of the Minister for Health, Dr Ryan, in order
8
DRAFT
”to ascertain whether there are significant differences in dental conditionsamongst school children living in different areas of the country and whethersuch differences, if they existed, could be related to the dietary intake of thechildren”.5
It was later correlated with the Irish National Nutrition Survey, which was first under-taken in 1956.6 The dental survey related to three age groups:
1. Children aged five and six years;
2. Children aged seven and eight years;
3. Children aged twelve and thirteen years.
Overall, 2,000 children were examined. In the first age group, decayed or missing teethrepresented 35.7% of the total number of teeth. In the second group, 41% was decayedand 6% missing. In the cases of children aged twelve and thirteen, 45% of the first teethwere decayed or missing, and 25% of the permanent teeth were decayed.The above statistics would seem to correspond to the account given by Dr O’Mullane
to the Committee:
“I worked in the School Dental Service in West Cork for a number of yearsin the mid 1960s. Children constantly had gum boils and toothaches andI spent all of my time travelling from town to town-extracting teeth. Thatwas all I could do. There was a general anaesthetic session almost every dayof the week in City Hall in Cork to extract the teeth of frightened childrenof frightened mothers; in other words we are talking about children with badteeth in the 1960”.[2]
The results from the dental caries survey indicated that the recommendation for anextra 325 dentists was very wide of the mark. Nor was the recommendation practicable.In 1953, only 70 dentists were employed in the Local Authority Services. This hadincreased to a mere 74 by 1960. According to figures from the National Archives, thecombined total of dental graduates from universities in the Republic came to 53. Ofthese, the majority emigrated as soon as they qualified.[2] Clearly, the Department wasfaced with an impossible situation and could not deal with the problem of dental carieson a treatment basis alone.One of the recommendations of the Dental Consultative Council’s Report was the
appointment of a full-time dental surgeon to the staff of the Department of Health “inorder that the Minister may be adequately advised on dental matters and in particular onthose relating to Local Authority Dental Services”.9 Seamus MacNeill was subsequentlyappointed to this key position. In outlining his new proposals for the Department,McNeil noted that:
“the prevalence of dental diseases, the problems involved and the cost ofadequately controlling them appear on the face of it almost insurmountablein view of our limited resources. At the present time we are trying to move
9
DRAFT
from a position where the only resort is the mass extraction of diseased teethdue directly to a general state of neglect. The resort to such radical measuresis not only incompatible with the function of public health but cannot beindefinitely tolerated by an enlightened administration”.10
Two key elements of a new strategy were to be “prevention” and “prophylaxis”.11
These were entirely in keeping with the later proposals for fluoridation. Until 1955,fluoridation had not been properly investigated by the Department.12
In March 1955, the Assistant Secretary of the Department, Paddy Murray, began anexamination of fluoridation following the publication of a statement on fluoridation inthe British Medical Journal of 26th February, 1955.13 The statement concentrated onthe main findings of the “United Kingdom Mission to report on the fluoridation of watersupplies in North America”.20 14
“Epidemiological studies in America have demonstrated beyond doubt thatamong children and adults who have been born and brought up in areas wherethe drinking water contains fluoride at a level of 1ppm or more, there is muchless dental caries than in areas were the water is free from fluoride. Comparedwith areas where the drinking water contains little or no fluoride there is 60%less dental caries among children aged 12 to 14 years and about six times asmany children have permanent teeth which are free from caries. . .We considerthat an artificially fluoridated water similar in its action to one containingnaturally derived fluoride. . .We have found no scientific evidence that there isany danger to health from continual consumption of water containing fluorideat a low concentration Many suggestions have been made that certain illeffects may nevertheless occur. We can only comment that the proving of anegative is extremely difficult”.15
The first Departmental Memorandum on fluoridation was submitted in April 1955.In May 1956, a decision was taken by the Minister for Health to establish the FluorineConsultative Council.16 In January 1957, Minister T.F. O’Higgins appointed the FluorineConsultative Council to advise on the following matters:
“whether with a view to reducing the incidence of dental caries it is desirableto provide for an increased intake of fluorine, and, if the Council considers itso desirable, to advise as to the best method of securing such an increasedintake and as to any safeguards and precautions necessary”.17
The Fluorine Consultative Council had eighteen members. Its Chairman was TomMurphy, Professor of Social and Preventative Medicine at UCD. There were five den-tists on the Council, including Seamus MacNeill of the Department, three doctors, twoengineers, two senior administrators, a vet, a geologist, a pharmaceutical chemist, theChairman of a County Council who was also a Senator and a research chemist. Mr. JimIvers from the Department of Health was Secretary of the Council.Minutes of the meetings of the Council indicate that it had less than an open mind on
the question of fluoridation. In fact, the Council could be characterised as being avidly
10
DRAFT
pro-fluoridation. Arguments put forward by organisations and individuals opposingfluoridation were immediately dismissed. At a meeting of the Council on March 12th,1957, Professor T Murphy, UCD,
“the Chairman, suggested that a letter such as that received from Mr. GerryNolan of 10 Albert Place East, Dublin, should be read in full to the Consul-tative Council as an example of the unreasoned arguments put forward bymost individuals”.18
Referring to the letter from Firinne, he said that “their objections were basedmainly on ‘spiras [sic]’ articles. He questioned the authenticity and the reli-ability of the writings. It was argued that no point was raised in any of theletters, which the Committee could not answer”.
The Chair suggested that all points could be answered under the following headings:
1. Harmful effects of fluoride as a poison. Arguments under this heading could beanswered on the grounds that no proof is offered in their support.
2. Different consumption of water by individuals make the calculation of a safe doseimpossible. Individual consumption does not vary widely in this country andanyway a wide safety gap is allowed when deciding the dose.
3. Fluoridation of water supplies causes teeth to harden and makes their treatmentimpossible. There is no evidence to support this argument.
4. Fluoridation only postpones dental decay. This is good in itself.
5. Arguments that fluoridation can have a harmful effect on the brain, etc. can bedismissed as unfounded.
6. The point regarding the benefits going to the aluminium industry does not affectthe question to be decided by the Committee.
7. The aministration of fluoride in tablet form is considered impracticable.
8. Hazards to operators, these can be overcome.
It is claimed that the Fluorine Consultative Council met on fifteen occasions, yet only theminutes of the above cited meeting survive. According to the Department of Health andChildren, the other minutes and documentation relating to the Fluorine ConsultativeCouncil meetings were destroyed by floods.19
The Fluorine Consultative Council came to the following conclusions:
1. Having considered all the information available to it on the relation between fluo-ride and dental decay the Council is satisfied that increased intake of fluorine willreduce the incidence of dental caries and that it is desirable to provide for suchan increased intake. The Council is further satisfied that the increased intake of
11
DRAFT
fluorine can best be provided by fluoridation of public water supplies to the levelof 1 part per million F.
In so recommending the Council is aware that quite 50% of the community wouldthereby benefit at present even if all public water supplies in the country werefluoridated but the percentage will increase according as public water supplies areextended.
2. Before any public water supply is fluoridated the Council considers that stepsshould be taken to assess the incidence of dental caries in children resident in thearea served by that water supply. The Council also considers that subsequent tofluoridation adequate steps should be taken to permit a proper evaluation of theresults.
3. Insofar as the engineering aspects of the fluoridation of public water supplies areconcerned, the Council sees no particular difficulty in the procedure as the methodsemployed in the addition of fluoride to a water supply are similar to those incommon use for the addition of other chemicals to water. The methods used inthe protection of public water workers handling fluoride salts are similar to thoseused in the handling of other chemicals which may have harmful effects and do notneed special description here.
4. The Council is in doubt as to whether local authorities have the necessary statutoryauthority to add fluoride to public water supplies. It recommends the introductionof any legislation, which may be necessary to enable Local Authorities to dischargethis function.
On the 8th October, 1958, the report from the Fluorine Consultative Council was pub-lished, together with a statement that the Government had accepted, in principle, therecommendations of the Council.The Government now wished to proceed as quickly as possible with a fluoridation
policy, as it was a far more attractive economic option than dealing with dental carieson a treatment basis. A “Memorandum for the Government’s Information” outlined thefacts:
“Some indication of the dental manpower and financial problems which wouldarise if it were decided to attempt to cope with dental caries by treatmentmethods alone may be gained from the fact that in order to match Nor-way’s dentist to population ratio, this country would need a further 1,250dentists, in addition to the present 625, at an extra cost to the communityof about £2.5 millions per annum. Present public authority expenditure ondental services here is under £0.5 million pounds per annum. The shortageof dentists in Great Britain and the attraction of highly paid employment fornewly qualified dentists there have already caused much difficulty in fillingof Local Authority Dental Posts. Even if there were no emigration of gradu-ates it would take many decades to increase dental manpower to the extentindicated.”20
12
DRAFT
The initial capital costs were estimated at £100,000, which would involve no charge tothe Exchequer. As a preventive health measure, fluoridation promised value for money.The central concern of the Department was how to put the recommendation of the
Council into legislative form. Although Local Authorities had the power and duty to pro-vide “pure and wholesome” water to members of the public, the addition of a substancelike fluoride would require new legal powers.Discussions in the Department centred on whether the new legislation would be “en-
abling” or “mandatory”. Initially, an Assistant Principal Officer in the Department, ina memorandum submitted on the 2nd December, 1958 to Mr. Paddy Murray, AssistantSecretary, recommended enabling legislation. He was of the view that mandatory legisla-tion would be unconstitutional. However, Mr. Murray took a different view and recom-mended mandatory legislation to the Secretary of the Department, Mr. O’Cinneide, whoin turn recommended mandatory legislation to the Minister, Mr. McEntee. On the 8th
December, 1958, the Minister approved the recommendation for mandatory legislationby his senior civil servants.21
Two key factors influenced the decision to opt for mandatory legislation. One wasthe problem of overlapping boundaries, for example, if Kildare decided to fluoridatewhile Dublin decided against, Dubliners would still have to drink fluoridated water ifthe supplies came from Kildare. These practical difficulties were alluded to by Dr Gavinwhen he came before the Committee .22
The second reason for opting for mandatory legislation was international evidencethat allowing local communities to decide on this issue would result in long, drawn-outdebates, making its introduction far more difficult. Mr. McEntee himself believed thatCouncillors simply did not have the competence to deal with “complicated questions ofpublic health policy” (Dail debates 9.11.60).Dail Debate of the Fluoridation Bill & High Court Case On the 5th April, 1960
the Second Stage Debate on the Fluoridation of Water Supplies Bill 1959 began. Inintroducing the Bill, Minister McEntee stated:
“This measure is intended to curb and reduce the incidence of disease whichnot only caused suffering, but also, because the damage it does may lead tograve disorders and prolonged ill health. The disease in question is dentalcaries”.23 The Minister claimed that, “the incidence of dental caries in thecountry is probably amongst the highest in the World”.24 The Minister wenton to claim that “dental decay . . . is not only a virulent source of sufferingand mental strain but often the root cause of economic hardship and financialloss”.25
The Minister also concentrated on the effects of this disease, dental caries, on children.
“For the past 40 years research into the problem of finding a prophylacticagainst dental caries has been intensively pursued in many countries. Allresults indicate that, if piped water supplies are available to the community,it is possible and easily practicable to build up in young children a highdegree of immunity from it”.26
13
DRAFT
The use of the word “immunity” suggests that the Minister believed that fluoride throughingestion somehow prevented this disease.He rightly pointed out that fluoride occurred naturally as a trace element, not only in
drinking waters but also in the “majority of foods, in vegetables, meats, cereals, fruit,fish and notably in tea”.27 It is a normal constituent of bones and teeth. In relation tothe prevention of dental caries he was quite explicit in saying that
“it would appear that an adequate intake of fluoride has a strongly inhibitingeffect on its development”.28
Again, this suggests that the Minister was of the belief that the ingestion of fluoride wasnecessary in preventing dental caries.Much of the evidence cited by Minister McEntee came from the New Zealand Com-
mission on the Fluoridation of Public Water Supplies. He quotes their report:
“fluoride is a natural component of all teeth and by hardening their mineralstructure it makes them more resistance by acids”.29
Interestingly, their report also states that the regular ingestion of a substantial excessof fluoride (more than 1.9 parts per million) in the drinking water may cause dentalfluorosis. This is the only mention of dental fluorosis by the Minister. Part 3 of thisreport also dismissed as absurd and entirely misleading the arguments contained in anti-fluoridation literature. In particular, Part 5 of the Commission’s Report rejects the viewthat fluoride is harmful to health. The Minister also stated that the American Medi-cal Association, the American Dental Association, the National Council, the College ofAmerican pathologists and the commission on chronic illness all sponsored and recom-mended fluoridation. To bolster his arguments the Minister quoted from the Pure WaterAssociation, which opposed fluoridation. In their submission to the Minister they statedunequivocally:
“it would be idle to deny that good grounds exist for believing that thepresence of fluorine in the diet, in some ways as yet unexplained, renders theteeth of young children resistant to decay”.
On the question of whether water fluoridation represented mass medication, he declaredit was not a medication but rather a nutrient. He also dismissed arguments that thisrepresented a grievous infringement of the rights of the individual. Public water supplies,he argued, did not belong to the individual but belonged to the community. Throughoutthe debate he studiously avoided the word “state”, which under the circumstances wouldhave been more appropriate, and continued to use the word “community”. The Ministersought to placate those with health concerns by stating that section 6 of the Bill wouldenable the Minister for Health to carry out health studies on a particular area.In the Senate on the 14th December, 1960 the Minister also dismissed the argument
that the problem of dental caries be tackled by expanding the facilities for treatingthe disease. According to the Minister there were only 620 dentists in the country andproportionately only one third of countries like Sweden and the USA. Even then countries
14
DRAFT
with the highest ratio of dentists to population could only treat properly one third ofthe people. We would therefore it seemed have to increase the number of dentists herenine fold to be able to tackle the problem adequately on a treatment basis.Most opposition Deputies accepted the merits of water fluoridation. They could hardly
do otherwise, as it was the main opposition party, Fine Gael, who had in fact set upthe Fluorine Consultative Council. Instead, they objected to the mandatory nature ofthe Bill, saying that it flew in the face of the Fluorine Consultative Council’s recom-mendation that enabling legislation be used. Many of the speakers drew attention toRecommendation 41 of the report, which explicitly provided for such enabling measures.The leader of the opposition, James Dillon, put it in these terms:
“if there is a principle involved at all here it is the principal of excessivebureaucratic control. We have Local Authorities, we maintain them and Ithink it is true to say that in general principle we should avoid transferringthe powers of these Local Authorities to the Custom House. As I would haveunderstood it, that was the general philosophy of all Deputies here in so faras this should be quoted as a precedent for further actions, I think it is a badprecedent”.30
He was fully supported by other Fine Gael Deputies. T.F. O’Higgins said,
“we must accord to Local Authorities the liberty which our democracy hasgiven to them, that is freedom of action”.
“this Bill has the same sense of compulsion, the same smell of dictatorshipabout it as any that might be produced by a person who fails to recognisethe integrity of the individual, who believes in the communist doctrine or thefascist doctrine that a person must be sub-ordinate to the interests of theState and not that the State is there to serve the interests of the individualif one believes in democracy, in Christian principles, in fair play, one mustreject as improper this proposed mass medication without the consent of thepeople . . . what has become of this country’s professed ideal of the voluntarysociety?”.31
The Seanad Debate took a similar direction. When challenged to name another coun-try in the world that has introduced fluoridation nationally, the Minister was forced toconcede that none existed:
“in relation to the question as to whether the parliament of any other coun-try than ours has accepted responsibility for empowering a Minister to securethat the public piped water supply will be fluoridated, I am not aware of any,but then if other countries do not carry their responsibilities, that is no justi-fication for our failing to accept them and if it happened that for one reasonor another the Swedish Parliament failed to live up to these responsibilities,I hope the Irish Parliament will live up to them . . . as you know somewhere,sometime by some person, a beginning must be made”.32
15
DRAFT
At the end of the Dail Debate, Richie Ryan, frustrated by the lack of engagement withthe subject in the Dail remarked,
“. . . I feel this House has not yet properly debated this radical proposal. Ofits one hundred and forty-seven members, I believe only ten members haveyet spoken their minds in public on this very important matter”.33
A number of Local Authorities refused to obey the provisions of the Fluoridation of WaterSupplies Act 1960. Leitrim and Tipperary Urban District Councils adopted resolutionsprotesting against water fluoridation. In April 1962, Cork Corporation passed a motion
“informing the Minister for Health that it wished to take no part in theproposed scheme of fluoridation of the public water supplies of Cork”.34
Following extensive lobbying by the Irish Dental Association, the Councillors reversedtheir decision. Also in 1962, Dublin Corporation withheld approval for the expenditureof £1,100 to purchase fluoridation equipment. Minister McEntee responded by issuingan ultimatum to the Corporation to fluoridate the water supplies by the 1st April, 1963.He threatened to abolish the Council and set up an enquiry, the cost of which wouldbe borne by those members who objected to the measure .35 At the beginning of themeeting, a letter from the Minister was read out by Mr Robert Briscoe, urging theCorporation to “fulfil its obligations” and “obey the law”. A decision on the issue hadbeen deferred from the previous meeting pending the outcome of a High Court actionprotesting the constitutionality of the Health Act by Mrs Gladys Ryan. The solicitoracting for Mrs. Ryan was Richie Ryan, T.D. who spoke vigorously against Mr. Briscoe’smotion.
Under such enormous pressure from Central Government, Dublin City Council eventu-ally voted 25 votes to 15 to authorise the necessary expenditure, following an acrimoniousdebate.
5.2 The High Court Case
There is little doubt that much of official certainty about the policy of water fluoridationcan be explained by the High Court Case presided over by Judge John Kenny, and theSupreme Court challenge which followed it.
While the High Court case has been subjected to interminable legal study and hasbeen quoted in Fluoridation Forum report, the Committee has not occupied itself withthe details of the case for a number of important reasons.
Firstly, the Committee is dealing with a health policy today that should and can bescrutinised by the Oireachtas just as for any other health policy that is being imple-mented today.
Secondly, Judge Kenny’s support for the conclusions of the Fluorine ConsultativeCouncil was based on the Council’s assertion that “no other vehicle or techniques forthe prophylactic application of fluorides can at present replace the fluoridation of drink-ing water as a public health measure” (Kenny J. 1963). The addition of fluoride to
16
DRAFT
toothpastes from the 1970s onwards allied to other equally effective dental interventionshave shown how unwise it was to be guided so completely by this assertion.Thirdly and of crucial significance in this matter, the decision of the High Court
relied on judicial interpretation of the scientific evidence by the learned judge. On thekey issue of “whether fluoridation of water is or may be dangerous to the citizens ofthe State” (ibid), Judge Kenny’s self-acknowledged reliance on one apparently expertwitness has since been shown to have been extremely unwise. In The Fluoride Deceptionby Christopher Bryson, 2003, the evidence of Prof Hodge of the US PHS is revealed tohave been less than reliable not to say entirely disingenuous, because of his undeclaredrole to protect US government strategic interests in fluorides.Following the legal verdict that “there is no reasonable possibility that it (fluoridation)
may involve an element of danger or risk to life or health to any of the citizens of thiscountry” (Kenny J 1963) it was all the more imperative for the Department of Healthshould apply the key provision of the legislation to investigate the other health effectsthat opponents had pointed to. But for the next forty years this crucial interventionwas simply overlooked. The Kenny judgement which has been quoted so often since cannow be seen to have been fundamentally flawed. Nevertheless it had profound socialand political significance because it has effectively silenced any proper media debate onfluoridation since that time.
5.3 The Fluoridation Forum
The then Minister for Health, Micheal Martin, set up the Fluoridation Forum in 1999.The Forum was to investigate all aspects of the Water Fluoridation Policy, dating backforty years, and the report was to be completed within a year.The fundamental problem for the Forum however soon emerged – how to meet the
minister’s wide terms of reference when virtually all previous research used to justifyfluoridation had been done by dentists. As had already been noted by the UK YorkReview, even this research whether of UK, Irish or international origin, could not berelied upon to inform policy because of its poor quality. And as for non-dental orgeneral research into fluoridation, the Minister himself confirmed it was needed when hereferred at the launch of the report to “the absence of scientific risk assessment of therisks” of fluoridation. Below are some of the reasons why the public had cause to beworried and why the Forum did not produce, contrary to the Minister’s assertion at itslaunch, “a credible and valuable report”.From the outset, the Forum’s membership was subjected to serious criticism. Oppo-
nents questioned the overwhelming representation of government employees and dentistswith very limited independent medical or toxicological expertise. Moreover the only med-ical group involved, Irish Doctors Environment Association, subsequently criticised theForum for publishing its report without answering their own and other health-relatedquestions, in particular the 50 Reasons to Oppose Fluoridation that were submitted inperson by Dr Paul Connett to leading Forum members. The issue of bias was raised atthe Committee by Dr Don MacAuley of Irish Dentists opposed to fluoridation:
“One of my reasons for refusing to attend the Forum in January 2001 was
17
DRAFT
that it was pro-fluoride and, therefore, it was not a serious, independent orfair assessment of fluoridation in Ireland.
The Minister referred to the open nature of the Forum but how open wasit? If we look at the Forum we can see it as another of the internationalfluoridation promoters. Professor O’Mullane is on a leaflet of the BritishFluoridation Society where he is promoting fluoridation to the elderly.
Other connections include the British Nutrition Foundation. Professor O’Mullanepresented at a 1999 conference. Their advice on improving oral health placedfluoridation at No. 2 and sugar reduction moved to No. 5.
Irish Dentists Opposing Fluoridation believe that tooth decay is not due tolack of fluoride but a sugary diet is a major factor. This member appears tofavour fluoridation before diet education.
Professor John Clarkson is past president of the International Association ofDental Research which fully endorses and strongly recommends the practiceof water fluoridation. Therefore, he would also not appear to be open onthis subject. National fluoridation supporters include Dr. Gerard Gavin.These people have made their position on fluoride clear to the media, inpublications and at conferences. Dr. Gerard Gavin has stated that ’weconsider fluoridation safe at the levels it is being used in Ireland”.
Dr. Maire O’Connor and Dr. Howard Johnson co-authored a report which stronglysupported the continuation of fluoridation. Dr. Joe Mullen was reported in the IrishMedical News as saying “fluoridation benefits dental health and adverse medical effectsare unproven”. (Health Committee, 10 July 2003)The failure to answer the fundamental questions about fluoridation has undermined
both the Forum and the Minister’s promise that it would allay the fears of all those whowere worried about fluoridation. Even those aspects which the report did address suchas the public perception of fluoridation, were not clearly reported in order to downplaythe finding that over 90% of public submissions were opposed to fluoridation.The report’s failings were further compounded by the Minister when he claimed that it
was based only on scientific and not anecdotal evidence. Within two months this claimwas rejected by international scientists (Scientific Critique of the Fluoridation ForumReport, October 2002 ) who exposed the lack of scientific scrutiny in the report. TheMinister was specifically criticised for not addressing the scientific evidence available inthe published literature and in particular that evidence that had been directly raised byDr. Connett and Dr. Limeback in their submissions to the Forum in Cork in October2000. Worse still the Forum was accused of not even being familiar with the internationalscience on the subject. (UK NHS York Review, September 2000)Other criticism of the Forum was made to the Committee in relation to matters
arising in the Food Safety Authority of Ireland in 2001 when it investigated fluoridatedwater used in making up infant formula. The Committee was disquieted to learn thatthe minutes of a meeting of its Scientific Committee, which recommended that parentsnot use fluoridated tap-water to make up infant formula, were subsequently changed to
18
DRAFT
state almost the exact opposite. The explanations given by Dr. Wayne Anderson in thisregard were unconvincing:
“At the meeting, nine of the 15 members of the committee were present andsix were absent. The nine members in attendance read through the report,listened to the discussions and accepted the report on behalf of the scientificcommittee, at which point I was correctly under the impression that thereport was passed by it.”
The meeting of the Fluoridation Forum was held a day or two after the scientific commit-tee meeting and so I presented the report as the conclusions of the scientific committee.In the preceding few days, some of the members who were not present at the scientificcommittee meeting contacted the Food Safety Authority of Ireland and the chairman ofthe scientific committee and basically said they felt that, having now read the report,it contained some errors and that it did not necessarily take account of all the availablescientific evidence. At that point the chairman said that, effectively, the report was nolonger supported by the majority of the scientific committee and I had to withdraw thereport at the next meeting of the Fluoridation Forum. (July 20, 2003)The former chairman of the Committee, Batt O’Keefe TD, reacted to this explanation
thus:Chairman: “It sounds like a real process mess. How many scientists of the overall
group were present when this was first adopted?”Dr. Anderson: “Nine out of 15; there were six absent.”Chairman: “Was it the six people who were not present who subsequently made the
objections to the scientific analysis and basis of it, or did members who adopted thereport make objections subsequently?”Dr. Anderson: “It was some of the absent members.” (10 July 2003) The Committee
believes that the Forum Report’s subsequent Risk Assessment on fluoride intake of Irishinfants consuming infant formula re-constituted with fluoridated water was an attemptto put scientific respectability on this volte-face by the FSAI. The manner in which thiskey recommendation was changed was both irregular and suspect.There were other contradictions between what the Forum recommended and what indi-
vidual members stated on a particular issue, in this case once again relating to fluoridatedwater in infant feed. One of its most prominent members, Dr. John Clarkson, Professorof Dental Health & Dean of Dublin Dental School & Hospital, further undermined thecredibility of the Forum on the issue of tap water and infant formula when he publisheda paper (with his colleague Dr. Jacinta McLoughlin) “Role of Fluoride in oral healthpromotion” in the International Dental Journal (2000) in the same year as the Forumwas at work. http://www.fdiworldental.org/assets/pdf/commission/97_6_1.pdf.It contained the following advice:
“Fluorosis and infant formulas – The risk of fluorosis resulting from the useof infant formulas has been reduced considerably as a result of the action ofmanufacturers in reducing the amount of fluoride in these products. However,infant formulas should still be prepared using non-fluoridated water”.
19
DRAFT
Recommendation 5 of the Report of the Forum of which Prof Clarkson was a leadingmember, advised something completely contrary –
“Infant formula should continue to be reconstituted with boiled tap waterin accordance with manufacturers’ instructions. Alternatively ready-to-feedformula can be used”.
The Forum website elaborates as follows but nowhere does it advise, as does ProfessorClarkson, using non-fluoridated water.
Question 3: Should I use fluoridated water to make up my baby’s feeds? Answer:Yes. The Forum recommends that parents continue to prepare baby feeds with boiledtap water and to follow the manufacturers’ instructions.“ It should be noted that nomanufacturer issues instructions to use fluoridated water.
Question 4: Is it okay to use bottled water to make up feeds? Answer: The Forumrecommends that you do not use bottled water to make up your baby’s feeds. Bot-tled water on sale in Ireland may contain salt which is not recommended for babies.”(was at http://www.doh.ie/publications/fluoridation/faqpar.html; full report athttp://www.dohc.ie/publications/fluoridation_forum.html)
While the Forum and its report have been regularly referred to in subsequent min-isterial statements, none of its thirty three conclusions have been implemented. Thisraises fundamental questions about fluoridation policy within the Department. And asadmitted by Forum member and Principal Dental Surgeon on 10th July, 2003, it is notacceptable that Health Boards have been left in limbo. Health Boards (HSE) still haveno new legal guidance on what concentration fluoride should be dosed at. Even at themost basic level of public approval, the Forum report clearly demonstrated that fluori-dation is extremely unpopular with the individual members of the public– for a wholevariety of reasons– who the Forum simply dismissed as poorly informed.
5.4 Aftermath of the Fluoridation Forum
While the Forum fell far short of expectation and achievement there is evidence to sug-gest that as a proper investigation of policy, it was compromised from the outset. Theminister appointed his most senior adviser on dental policy, the Chief Dental Officer, tothe Forum. How could an objective assessment of policy be achieved if the prime andlong-time exponent of that policy was a leading player on the investigation? Fluorida-tion has been so central to Irish dental policy for many years that it would have beeninconceivable for any forum to conduct a fair investigation with the prime advocate forthe policy being an integral member of the review.
Several members of the Committee expressed their reservations at the time the Forumwas announced, however it was not until the Forum released the report a full year laterthat its limitations were fully revealed. Its key recommendation — to reduce the fluorideconcentration from 1 ppm to 0.7 ppm in response to the increase in dental fluorosis —was a totally inadequate response to the over-exposure to fluoride in children. Equallyinexplicable was the eighteen month delay before the body that was set up to implement
20
DRAFT
the far-reaching recommendations of this “credible and valuable” report, first met inApril 2004.
There was another explanation for the policy drift following the Forum report. Someeight months after its publication, in May 2003, the same Chief Dental Officer anddepartmental spokesman on fluoridation policy, resigned to take up a position in theprivate sector. At the same time that the allegedly far-reaching recommendations of theForum were to be implemented, the top government adviser on dental policy resigned.The Committee finds this further compelling evidence to question the wisdom of theMinister to have appointed the Chief Dental Officer to membership of the Forum.
Whatever the reasons for its failure, the Forum did consult experts from the UK,Canada and the United States. It started work just after the publication of the YorkReview. This Review revealed alarming results of fluorosis in a population exposed todrinking water fluoridated at the concentration legally enforced in Ireland. Almost half(48%) of people in a fluoridated area such as Ireland showed some form of dental fluorosisand the Review found a clear dose response relationship between the concentration offluoride in water and fluorosis. Dr. Don MacAuley of IDOF is of the view that thiskey finding was not addressed properly by the Forum. Dr. Paul Connett has also madeit clear that the Forum did not answer the scientific evidence presented to it. His fiftyquestions about fluoridation were not addressed in the Forum Report.
6 Water Fluoridation and Dental Caries
It is frequently suggested that water fluoridation has revolutionised dental health in Ire-land, helping reduce the incidence of decay by about 70%. According to the Departmentof Health,“in Ireland the critical factor which led to improvement of dental health wasthe decision to fluoridate public water supplies in the 1960s”.36 The former Minister forHealth Micheal Martin TD stated;
“The impact on oral health has been dramatic in Ireland since that decisionback in the 60s to have mandatory fluoridation of public water supplies.And we shouldn’t underestimate the dramatic impact on dental health inIreland, it has really transformed the quality of teeth of Irish people in thoseintervening 30-odd years”.37
When the concept of adding fluoride to the water supplies was proposed in the USA in the1940s, it was suggested by its promoters, such as the American Dental Association, thatit would help reduce dental decay by about 60–70%. However, recent reviews have castconsiderable doubt on the accuracy of these claims and have suggested that the benefitis much less.38 This section will detail the evidence presented to the Committee on theeffectiveness of water fluoridation in Ireland, and will be supplemented by additionalnational and international research.
21
DRAFT
6.1 What is Dental Caries, and How Can Fluoride Help?
‘Dental caries’, which is measured scientifically as ‘decayed, missing or filled teeth’(DMFT). According to the Oral Health Research Centre, dental caries, or dental de-cay,
“begins with a small patch of demineralised (softened) enamel at the toothsurface, often hidden from sight in the fissures (grooves) or in between teeth.The destruction spreads into the dentine (the softer, sensitive part of thetooth beneath the enamel). The weakened enamel then collapses to form acavity and the tooth is progressively destroyed”.39
The cause of dental caries is the action of acids on the enamel surface, produced whensugars react with bacteria present in the plaque or soft film on the teeth. This resultsin demineralisation, which is a loss of calcium and phosphate from the enamel. Whenthere is consistent breakdown of the enamel surface, this leads to a cavity.
Fluoride has been proposed as a solution in helping slow down the process wherebythe enamel loses calcium and phosphate when exposed to acid, following ingestion offood and drinks which contain sugars. It is suggested that it also helps to ‘heal’ surfaceswhich show early signs of calcium or phosphate loss.40 According to Dr. Gerard Gavin,the former Chief Dental Officer for the Department of Health,
“Our knowledge about how fluoride works is that the key thing is havingfluoride consistently present in the saliva, available for the tooth surface sothat when you eat sweet food you get the deposition of the fluoride into thetooth surface and it makes the tooth surface very hard”.41
In the 1950s and 1960s, before fluoride was added to toothpastes and other oral careproducts, the level of fluoride in the diet was very low. A programme to add it to thedrinking water supplies was commenced. This section will take a number of perspectivesin looking at the evidence in assessing the success of this programme.
The first section will look at the reduction in dental decay as it stands today versus the1950s and 1960s in Ireland, before water fluoridation commenced. A number of sectionswill look at the evidence of the impact of water fluoridation by comparing the decaylevels in fluoridated and non-fluoridated areas. In addition to assessing the continuingneed for water fluoridation in Ireland, there will also be an analysis of the possible impacton oral health of discontinuing water fluoridation.
6.2 Water Fluoridation and Dental Caries in Ireland
The evidence on the effectiveness of water fluoridation in reducing dental caries in Irelandis complex, and needs to be supplemented by additional information from an interna-tional perspective. Professor Denis O’Mullane of University College Cork informed theCommittee that:
22
DRAFT
Table 1: Dublin Region; dmft 1963 versus 1997.43
Dublin City 1963 1993 1997
dmft 12 Year Olds 6.1 1.2 1.1
“There have been ongoing studies in Ireland since the commencement ofwater fluoridation in Dublin in 1964, all of which, as Dr. Gavin pointed out,have shown that water fluoridation is highly effective in reducing the level ofdental decay in children. . . ”
(See Table 6.2 on page 23)
“. . . table 3 in enclosure contains the figure 6.4. This is the mean number ofdecayed, missing and filled teeth (dmft) among five year old children in theSouthern Health Board area in 1963 . . .
. . . The figures for 1995 were 1.2 and 2.5. This indicates a dramatic improve-ment. The figure of 1.2 applies to children living in communities served withfluoridated water supplies”.42
Statistics from the Department of Health also highlight the decrease in dental decayin Dublin in the period since fluoridation was introduced.Statistics from the Southern Health Board and the Department of Health (see Table 2
on page 25) highlight a reduction in decay between the 1960s and the 1990s in the SHBregion of 81%, and in Dublin also of 81 % in 12-year old children.Studies from various health boards also attest to improvements in oral health since
the introduction of water fluoridation in the 1960s. Statistics from the Western HealthBoard region in 1991 show a decrease in rates of dental decay in fluoridated communitiesof 80% for 5 year olds, 70% for 8 year olds and 61% for 12 years olds”.The Mid-Western Heath Board Survey of Oral Health of Children and Adolescents
1997 (see figure 1 on page 24)quantified the reduction in dental caries between 1961 and199745. Assessing the reduction in dental caries between periods before water fluoridationcommenced (1961/63) and 1997, there can be seen dramatic decreases in the number ofdecayed, missing and filled teeth, as in the chart below.There were significant reductions in DMFT in all four age groups between 1961 and
1997:73% among five year olds, 68% among eight year olds, 71% among twelve year oldsand 63% among fifteen year olds. The study concludes, “this improvement is due to theintroduction of water fluoridation following the Health (Fluoridation of Water Supplies)Act 1960 and to the introduction of fluoridated toothpastes in the early 1970s”46.According to the Dental Health Foundation Ireland:
“The introduction of water fluoridation in Ireland nearly 40 years ago islargely responsible for the 70% falls in levels of tooth decay. Dental Healthsurveys carried out by the state in 1963, 1984, 1989 and 1990 confirm thatwater fluoridation has had a major impact on the oral health of Irish childrenand adults”.47
23
DRAFT
0
1
2
3
4
5
6
7
8
9
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
1961/’63 Pre-Fluoridation19841997
Figure 1: Change in Tooth Decay 1961/’63–1984–1997 in 5, 8, 12 and 15 Year Olds inFluoridated Area in MWHB Region
The former Minister for Health, Micheal Martin T.D. has also commented that
“we have had fluoridation for 40 years, it has proven its worth. It has reduceddental decay by 70%, a staggering achievement. . . and the results are therein terms of dental health, they cannot be challenged”.48
6.3 The Reduction of Dental Caries in Developed Countries
In analysing the statistics from Ireland, it is necessary to quantify the contribution thatwater fluoridation has made in achieving improvements in oral health. In relation tothe overall reduction in dental decay, it is necessary to go beyond correlations thatshow reductions in decay since the introduction of water fluoridation. It is necessaryto compare with cases in which there have been no water fluoridation programmes.According to Dr. Hardy Limeback, Head of Preventive Dentistry in the University ofToronto, and past President of the Canadian Dental Association, “dental decay hasdeclined worldwide, even in the non-fluoridated areas dental decay rates are low”.49
Statistics from the World Health Organisation’s (WHO) Oral Health Country/AreaProfile Programme confirms this fact, highlighting that decay rates have been decreasingin all countries.50 The comparison below is made between European countries that havea WHO decayed, missing, filled teeth (DMFT) statistic for both the 1970s and 1990s.
As seen in table 3 on page 26 between the 1970s and 1990’s, commencing with DMFTrates largely similar to Ireland’s, the average percentage reduction in DMFT in Euro-pean countries has been 68%. Mostly this has been achieved without water fluoridationprogrammes (only 10% of UK water supply is fluoridated, 3% in Spain, and the city ofBasel in Switzerland). This average percentage reduction in DMFT scores mirrors the
24
DRAFT
Table 2: Mean dmft in the Western Health Board Region 1961–1991
Age Group 1961–1963 1991
5 Years 5.0 1.0
8 Years 1.4 0.4
12 Years 4.2 1.6
reduction that has taken place here in Ireland, where 73% of the population consumefluoridated water.
In Ireland, reductions in the occurrence of dental caries took place at near equal ratesin both the fluoridated and non-fluoridated areas. Table 4 on page 26 using statisticsalso from the World Health Organisation, shows the reduction in DMFT for 12 year oldsin fluoridated and non-fluoridated regions in Ireland between the 1980s and 1990s.51
The level of dental caries is decreasing at near similar rates in both fluoridated andnon-fluoridated areas for 12 year olds.
It has been suggested by various Health Boards in Ireland that the reduction in decayin non-fluoridated areas is probably a result of fluoride. The 1997 Mid-Western HealthBoard study suggests that the reduction in decay in non-fluoridated areas may possiblybe because of the “almost universal use of fluoride toothpaste by children in 1997”, andalso due to the “consumption in non-fluoridated areas of foods and drinks which containfluoride due to their being processed with fluoridated water in urban areas.”52
In 1986, a review of research into the effectiveness of water fluoridation in eight coun-tries cited a large number of studies which indicated that there were large reductionsin dental caries occurring in numerous non-fluoridated areas in Australia, Denmark,Holland, New Zealand, Norway, Sweden, the UK and the US. Author Mark Diesendorfstressed that “the magnitudes of these reductions are generally comparable with thoseobserved in fluoridated areas over similar periods of time”.53 The review concluded that:
1. There have been large temporal reductions in caries in non-fluoridated areas of atleast eight countries.
2. There have been large temporal reductions in several “fluoridated” areas whichcannot be attributed to fluoridation.
3. The absolute values of caries prevalence in several fluoridated areas are comparablewith those in several non-fluoridated regions of the same country.
Research published as far back as 1981 in the US also highlighted that there was signif-icant reductions in dental caries in non-fluoridated areas. Between 1958 and 1978, Dr.Robert Glass, a researcher at the Forsyth Dental Centre in Boston studied tooth decayin two non-fluoridated Boston suburbs, Norwood and Dedham. Dr. Glass examined theteeth of 1776 children in the school systems of these two communities and discovered,over the course of 20 years, a 50 percent drop in DMFT.54
25
DRAFT
Table 3: WHO Oral Health Country /Area Profile Programme
Country Year DMFT % Decrease
Austria 1973 3.51997 1.7 51%
Belgium 1972 3.11991 2.7 15%
Denmark 1978 6.41995 1.2 81%
Finland 1975 7.51994 1.2 8%
France 1975 3.51998 1.9 46%
Germany 1973 6.01994 2.6 56%
Ireland 1972 5.41993 1.4 72%
Italy 1978 6.91996 2.1 69%
Netherlands 1974 8.21992 0.9 89%
Norway 1973 8.41993 2.1 75%
Portugal 1979 4.61999 1.5 67%
Sweden 1977 6.31999 0.9 85%
Switzerland 1975 9.91992 1.1 88%
UK (GB & NI) 1973 4.71996–97 1.1 76%
Table 4: DMFT 12 Year olds - Ireland–WHO Oral Health Country –Area ProfileProgramme
Region Year DMFT % Reduction
Fluoridated 1984 2.21993 1.4 36 %
Non-Fluoridated 1984 3.01992 2.1 30 %
26
DRAFT
In explaining the general decline in the prevalence of dental caries in both fluoridatedand non-fluoridated countries world-wide, the Royal College of Physicians of Irelandproposes that this may have resulted from “factors such as the changing patterns ofsugar consumption, changes in oral hygiene practices, dental screening and increasingawareness of the importance of oral health”, as well as “the widespread use of fluo-ride supplementation, especially fluoride toothpastes”.55 It must be acknowledged thatIreland has also benefited from these dietary and oral health advances attributed toreducing dental caries in other European countries, whilst at the same time carryingout the programme of adding fluoride to the public piped water supplies. This makes itdifficult to identify the benefits derived solely from water fluoridation.Reinforcing the rationale put forward by the Royal College of Physicians of Ireland,
Diesendorf’s 1986 review paper also affirms that:
“The main causes of the observed reductions in caries are changes in dietarypatterns, possible changes in the immune status of the populations and,topical fluorides. Indeed, a promising explanation is that the apparent benefitfrom fluorides is derived from their topical action.”56
A number of other studies have also assessed the reduction in dental caries occurringacross the industrialised world, and concluded that the decline ‘cannot be all attributedto the work of fluoride.’57 58 59
A significant international perspective on the trend of reducing dental caries and thecontribution from water fluoridation has come from New Zealand. In New Zealandthe National Health Service Plan examines the teeth of every child (98 per cent of 5–13 year olds, and 68% of pre-school children).60 Therefore available to researchers is acomplete data bank rather than surveys. Whilst for a number of decades the reductionin dental caries had been attributed solely to water fluoridation, in the 1980’s, Dr. JohnColquhoun, then Chief Dental Officer of Auckland, graphed the downward trend indental caries over a 50 year period, whilst simultaneously graphing the introduction offluorides (water and fluoridated toothpastes) to the New Zealand population (see figure2 on page 28).61 According to Dr. Colquhoun it shows “that tooth decay had started todecline well before we had started to use fluorides. Also, the decline has continued afterall children had received fluorides all their lives, so the continuing decline could not bebecause of fluoride”, and therefore occurred independently of the introduction of waterfluoridation. Dr. Colquhoun concluded that “fluorides (water and toothpastes), whilepossibly contributing, could not be the main cause of the reduction in tooth decay”.62
Again, Dr. Colquhoun proposes that the reduction in decay is due to a rise in thestandard of living of most people in industrialised countries, signified by changes suchas improvements in diet, and increased oral health awareness. In 1998 de Liefde alsoanalysed the decline in tooth decay in New Zealand, and also concluded that “an expla-nation of the convergence of caries prevalence in fluoridated and non-fluoridated areassince the 1970s may require a re-assessment of the fluoride effect. This convergence, andthe overall decline during the last decade without known additional fluoride supplemen-tation, suggest that factors other than fluoride, such as food additives and antibiotics,may have contributed”.63
27
DRAFT
Figure 2: 50 year decline in tooth decay of 5 year olds in New Zealand
28
DRAFT
Dr. Hardy Limeback, addressing the Committee, referred to the possible reasons forthe decline in tooth decay in both fluoridated and non-fluoridated areas:
“We know that dental decay rates have decreased world-wide without fluorideintervention, because of many factors, including better general health, an-tibiotics, preservatives, better diets, sugar substitutes in the diet. There aremany good reasons why dental decay has declined throughout the world”.64
6.4 Water Fluoridation and a High Sugar Diet
Although most of Europe has achieved similar oral heath gains to Ireland without wa-ter fluoridation, it has been pointed out by the Department of Health that Ireland’sneed for a ‘water’ fluoridation programme, above the benefits derived from fluoridatedtoothpaste, is due to Ireland’s high consumption of snacks and confectionery, wherewater fluoridation can offer additional benefits to counteract the high consumption ofsugar in our diet. According to the Department of Health, the main reason for the de-crease in dental decay in areas and countries where there is no water fluoridation is the“widespread availability of fluoridated toothpastes”. Addressing Ireland’s need for waterfluoridation due to dietary reasons (in addition to the use of fluoridated toothpastes),the Department has also stated:
“However, in areas where the level of risk is high with high frequency con-sumption of sweets and confectionery the use of fluoridated toothpastes aloneis insufficient to prevent dental decay. A recent survey of adolescent snackingpatterns in 19 European countries revealed that Irish and Scottish childrenwere the worst”.65
However, statistics from the World Health Organisation appear to offer an alternativeperspective on this dietary rationale. Looking at the same countries (see table 5 on page30)as detailed above for DMFT scores, Ireland ranks only joint 8th in relation to theamount of ‘sugar consumed per capita’. That is, there are 8 European countries aboveIreland that consume a ‘higher’ per capita volume of sugar annually, with countriessuch as Austria and Sweden consuming over 35% more sugar per capita than Ireland.66
However, significantly, compared to other European countries, dmft figures for 12 yearolds place Ireland only sixth for tooth quality,67 despite Ireland being the only Europeancountry operating extensive water fluoridation programmesDr. Liz Cullen from the Irish Doctors Environmental Association has stated that the
groups opposition to water fluoridation was grounded in a number of principles, onebeing that “decay was not caused by a lack of fluoride, rather the presence of sugar”:
“We are not fluoride deficient. We support the practice of giving iron topeople who are anaemic or to women who are pregnant because their ironstores are depleted, but we are not fluoride deficient and dental decay is notcaused by an absence of fluoride”.68
As mentioned above by Dr. Limeback, one the possible explanations for the reductionof dental caries in Ireland over the 30 years of fluoridation (and in other developed
29
DRAFT
Table 5: Sugar Consumption Kg/Capita/ Annual - WHO Oral Health Country/ AreaProfile Programme
Rank Country Sugar Consumption(Kg/Capita/Year)
1 Sweden 52
2 Austria 50.1
3 Switzerland 44.1
4 Norway 41.7
5 France 41.2
6 Belgium 40
7 Finland 39
Netherlands 39
8 Denmark 37
Germany 37
Ireland 37
9 UK 35
10 Portugal 29
11 Italy 26
countries) is due to an improvement in diet, with just one of the measurements of thisdietary improvement being a general decrease in sugar consumption. The Departmentof Health has confirmed that the cause of dental caries is directly related to factors inthe diet such as sugar:
“Ireland like many other developed countries suffered from an epidemic ofdental disease which began in the mid 19th century and which has onlyrecently come under control. The main reason for the epidemic was thewidespread availability of refined sugars which occurred at the time”.69
Extrapolating the argument put forward by Dr. Limeback, an improvement in the dietin industrialised countries should result in a corresponding decrease in the consumptionof sugar, resulting in a decrease in dental caries. As mentioned above, The Royal Collegeof Physicians have also concurred that the reduction in dental caries in both fluoridatedand non-fluoridated communities is due to a number of factors, such as ‘the changingpatterns of sugar consumption’.70 However, a report in 1996 by O’Mullane et al71 sug-gested that the reduction in consumption in sugar by Irish people between the 1960sand 1990s cannot totally explain the reduction in dental caries over the same period oftime;
“Annual sugar disappearance figures for the period 1963 to 1979 were ap-proximately 46 kilogrammes per person per year, declining to approximately40 kilogrammes per person per year between 1986 and 1988. Between 1989
30
DRAFT
and 1993 a further small decline to approximately 37 kilogrammes per personper year occurred”.72
The report concludes
“these sugar disappearance figures do not account for the large decline in theprevalence of dental caries among children and adolescents in the Republicof Ireland over the last 30 years”.
Therefore it can be concluded that the reduction in sugar consumption cannot be the‘sole’ reason for the reduction in dental decay in Ireland (70% reductions). However withan overall 20% reduction in sugar consumption in Ireland occurring over the period ofthe water fluoridation programme, it is probable that this 20% reduction accounts forat least 20% of the total 70% reduction in dental decay as evidenced in Ireland over thisperiod.It should be stated that ‘reduced sugar consumption’ is only one measurement of an
improvement in a populations’ diet, and many factors possibly aiding the reduction thedental caries have been cited above. Considering that the reduction in dental cariesin Ireland is commensurate to a reduction in sugar consumption (a 20% reduction),and sugar is the main cause of dental caries, this should add credibility to the variousarguments proposing alternative reasons for reduced caries other than water fluoridation,rather than water fluoridation being the sole or main agent of change.
6.5 A Comparison in DMFT between Ireland and Scotland -
Countries with Similar Dietary Patterns.
To gain a further understanding of the possible impact of water fluoridation, it is nec-essary to focus on the differences in rates of decay in fluoridated areas compared tonon-fluoridated areas. As diet, and specifically sugar consumption, is the main cause ofdental caries, in making comparisons with other “non-fluoridated” countries, it is advis-able to compare Ireland’s DMFT to countries with similar dietary patterns to establishif there are any differences, which could subsequently be attributed to the effect of waterfluoridation.Dr. Gerard Gavin, in his presentation to the Committee chose a number of studies
“which demonstrate that fluoridation is still very effective in Ireland”, one of them beinga study showing the difference between DMFT scores in Dublin (fluoridated) versusGlasgow (non-fluoridated);73
“In a recent European study looking at 19 European countries, the snackingand confectionery eating habits of children in Ireland and in Scotland arealmost identical. They are the worst in Europe. We are ’top of the chocs’ inthat regard.
The only difference between the two cities was that Dublin was fluoridatedand Glasgow was not. When we look at the statistics for 12 year old childrenwe, find that in Dublin the average number of decayed, missing or filled teeth
31
DRAFT
Table 6: Indicators of dental caries in four cities in Ireland and the United Kingdom
City Mean DMFT Caries Free Children
London 1.27 50%
Edinburgh 1.39 47%
Dublin 1.48 43%
Glasgow 2.7 50%
Edinburgh 1.39 24%
was 1.48, in Glasgow 2.7, giving a 45% difference in the decay levels betweenthe two places”.74
The Department of Health has cited this study as “a good indication of the additionalbenefit provided by water fluoridation when other risk factors are similar”.75 However,this study cannot be taken to act as conclusive evidence of water fluoridation’s effective-ness, as it conflicts with the results of an extension of this study carried out two yearslater; which was not brought to the attention of the Committee by the Department ofHealth. In 1994, Downer et al extended the study to 12-year old children in North Lon-don and Edinburgh.76 Apart from Dublin, none of the other three cities had artificialwater fluoridation. The results of this study (see table 6.5 on page 32) show that bothEdinburgh and London had ‘lower’ decay rates than Dublin, achieved without water flu-oridation. Whereas Dublin had a thrift of 1.48, Edinburgh and London, non-fluoridatedcities had thrift rates of 1.39 and 1.27 respectively.
Specifically addressing these results, the Royal College of Physicians of Ireland hassaid;
“The, findings that children in Dublin which had fluoridated drinking wa-ter supplies had a higher DMFT than their counterparts in non-fluoridatedLondon and Edinburgh appeared paradoxical, and effects other than waterfluoridation were considered. The comparatively low caries level found inLondon and Edinburgh was considered to reflect in part the effect arisingfrom the use of dentifrices containing fluoride”.77
On comparing the number of 12 year old children in these studies who had ‘no’ den-tal decay, it should be noted that Dublin’s percentage of caries free children of 43%,compares closely with Edinburgh’s 50%. In Glasgow however, only 24% of the childrenhad no dental decay. These comparisons could indicate that Edinburgh provides a moresuitable benchmark for Dublin than Glasgow. If Dr. Gavin’s 1992 study acted as a ‘goodindication of the additional benefit of water fluoridation’, the evidence of the subsequent1994 study must thereby cast serious doubt over this proposed ‘additional benefit’.
Further comparisons are made in later sections between ‘fluoridated Ireland’ and acomparable non-fluoridated country. However before fully investigating the effect of wa-ter fluoridation by comparing studies in fluoridated communities versus non-fluoridated,
32
DRAFT
it is necessary to take note of the findings of the Review from the York University NHSCentre for Reviews and Dissemination, perhaps the most comprehensive review of theeffectiveness of water fluoridation, (Known elsewhere in this report as the York Review.)
6.6 The York Review
In September 2000 the review team at York University presented its report ‘Fluoridationof Drinking Water: A Systematic Review of its Efficacy and Safety’.78 Commissionedand funded by the UK Department of Health, the ’York Review’ set out to establisha number of perspectives in relation to water fluoridation. Three of these objectivesrelated to the effectiveness of water fluoridation, with the objectives stated as follows;
1. Does Fluoridation of Drinking water supplies prevent caries?
2. If Fluoridation is shown to have beneficial effects, what is the effect over and abovethat offered by the use of alternative interventions and strategies?
3. Does Fluoridation result in a reduction of caries across social groups and betweengeographical locations?
The York Reviews findings, as stated in the British Medical Journal were that “a system-atic review of water fluoridation reveals that the quality of the evidence is low. Overall,reductions in the incidence of caries were found, but they were smaller than previouslyreported”.79 According to the review team “the studies were of moderate quality (levelB), but of limited quantity”.80 There was said to be serious shortcomings in the researchproving the dental benefits of water fluoridation. The results highlight that: “The mostserious defect of these studies was the lack of appropriate analysis. Many studies did notpresent an analysis at all, while others only did simple analysis without attempting tocontrol for potentially confounding factors. While some of these studies were conductedin the 1940s and 50’s, prior to the common use of such analysis, studies conducted muchlater also failed to use methods that were commonplace at the time of the study”.81 Thereview also stated:
“To have clear confidence in the ability to answer the question in this ob-jective, the quality of the evidence would need to be higher. The failure ofthese studies to deal with potential confounding factors or to provide stan-dard error data means that the ability to answer the objective is limited”82
However the York Report did conclude that there was some benefit from water fluo-ridation, however this benefit was smaller than previously believed.The main findings in relation to reduced dental caries, as stated in the report were as
follows;
“The degree to which caries is reduced, however, is not clear from the dataavailable. The range of the mean difference in the proportion (%) of cariesfree children is -5.0 to 64%, with a median of 14.6% (inter-quartile range 5.05,22.1%). The range of mean change in dmft/DMFT score was from 0.5 to
33
DRAFT
4.4, median 2.25 teeth (inter-quartile range 1.28, 3.63 teeth). It is estimatedthat a median of six people need to receive fluoridated water for one extraperson to be caries-free”.83
The findings of the York report will be addressed further in this chapter.
It should be pointed out that there has been serious constructive criticism levelledat the review team for numerous omissions that are claimed would have offered a morecomplete and rounded perspective on the effects of water fluoridation.
An example of this criticism comes from Paul Connett, Ph.D 84 (who was a peerreviewer of the report). One of the examples of the omissions outlined by ProfessorConnett in relation to the benefit to teeth was as follows:
“I am extremely surprised that the York team included the early studies fromNewburg versus Kingston Ast (1951)”, (which proved the dental benefits ofwater fluoridation), “however, if it was deemed appropriate to use Ast (1951)data, then it is important to note that analysis of the teeth of the children inNewburg (still fluoridated) and Kingston (still unfluoridated) was repeatedin 198685 and 1995.86 In 1985 there was little difference in the DMFT valuesamong the children in the two communities and in 1995 the average DMFT’sin Kingston (unfluoridated) were slightly better than Newburg”.87
Professor Connett highlighted that had the review included certain research papersthat were actually omitted, it would have further lowered the resulting effectiveness ofwater fluoridation, which as mentioned above concluded a 14.6% benefit.
Although the results of the York Review suggested a benefit from fluoridation muchlower than previously heralded, John Hunt, Chief Executive of the British Dental As-sociation commented: “The compelling evidence provided by the review gives Ministersan opportunity to improve the quality of life of many thousands of young children.”88
On publication of the York Review in the British Medical Journal, the Associate Editorof the journal, Douglas Carnall, expressed his personal viewpoint as follows; “Previouslyneutral on the issue, I am now persuaded by the arguments that those who wish to takefluoride (like me) had better get it from toothpaste rather than the water supply”.89
6.7 Studies in Ireland Assessing the Difference in Decay levels
between Fluoridated and Non-Fluoridated Areas.
Section 6 of the Health (Fluoridation of Water Supplies) Act, 1960 requires the Ministerfor Health to conduct surveys into aspects of health of persons who receive fluoridatedwater. There have been numerous ‘dental’ health studies conducted in Ireland by thevarious health boards in conjunction with University College Cork since the 1960’s, whichmostly indicate a lower DMFT score in areas with water fluoridation programmes thanin non-fluoridated areas.
In 1984 the Minister initiated such a survey of Children’s Dental Health in Ireland. Thiscomprehensive study investigated the level of decay, missing and filled teeth and surfacesin 5, 8, 12 and 15 year olds, and found statistically significant differences in decay rates
34
DRAFT
1.5
2
2.5
3
3.5
4
4.5
5
5.5
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 3: Mean DMFT for 5, 8, 12 & 15 year olds in 8 Health Boards, 1984
in fluoridated versus non-fluoridated (F versus NF) areas. The sample looked at childrenin the Eastern, Midland, Mid-Western, North-Eastern, North-Western, South-Eastern,Southern, and Western health board regions.90
As evidenced in figure 6.7 on page 35), the percentage difference in dmft scores influoridated areas versus non-fluoridated areas in the 1984 study is as follows; for 5 Yearolds (40% difference), for 8 year olds (23% difference), for 12 year olds (21% difference),and for 15 year olds (24% difference). In his presentation to the committee, Dr. GerardGavin, Chief Dental Officer for the Department of Health discussed the results of theEastern Health Board study of 1997:
“The Eastern Health Board study of 1997 on page six, again examiningfive year olds, shows that, in fluoridated areas, there is an average of onedecayed, missing or filled tooth and, in non fluoridated areas, an average of1.7 decayed, missing or filled teeth, giving a difference of 41% more decay inthe non-fluoridated areas”.91
There have been a number of studies conducted by the various heath boards in the1990s, which show varying benefits from water fluoridation. The Mid-Western HealthBoard Survey of Oral Health of Children and Adolescents 1997, directed by Oral HealthServices Research Centre, University College Cork, where 67% of the area is fluoridated,also shows benefits from water fluoridation.92 Over the four age groups assessed, 5, 8, 12and 15 year olds, the average difference in decay rates between fluoridated communitiesand non-fluoridated communities was 30%. Figure 4 on page 36 below shows statistics foreach individual age group for the total results from the three areas, Clare, Limerick andTipperary, showing overall differences in DMFT between fluoridated and non-fluoridatedareas.
35
DRAFT
0.5
1
1.5
2
2.5
3
3.5
4
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 4: Mean DMFT for 5, 8, 12 & 15 year olds in MWHB, 1987
However, it needs to be pointed out that when the results from the three regionsare assessed individually, an alternative perspective on the benefit of water fluoridationcan be ascertained. Assessing the three areas separately, it can be seen that the mostsignificant statistical differences in fluoridated and non-fluoridated areas can be seen inone of the three areas, Limerick, (see figure 5 on page 37).
Of significance are the results from Clare, where according to the study “the levels oftooth decay are similar in both fluoridated and non-fluoridated areas”. As mentioned inthe report, figure 6 on page 38 highlights that there is little or no difference in tooth decaylevels in Clare in fluoridated (F) versus non-fluoridated (NF) areas. (Of the three areasin the study, Clare was the most heavily fluoridated, 73% of the population, comparedto Limerick (67%), and North Tipperary (49%))
In relation to Tipperary, although there are differences in ages 5, 8, and 12, thedifference in DMFT for 15 year olds differs very little in fluoridated versus non-fluoridatedareas (about a 7% difference), as can be seen in figure 7 on page 38.
The report notes that a fluoride mouth-rinse programme was undertaken extensively insome of the non-fluoridated areas of Clare and North Tipperary, and therefore this mayexplain, for example, the little or no difference in F versus NF areas in Clare, and smallerdifferences in North Tipperary. However the report also mentions that the mouth rinsewas not offered to 5 year olds.93 Considering that there is very little difference in DMFTfor 5 year olds in F Versus NF in Clare (a trend which as mentioned also characterises 8,12 and 15 in Clare), and there is a statistically significant difference in 5 year old DMFTin Limerick and Tipperary, the fluoride mouth-rinse programme does not seem to offer aconvincing explanation for the general trend in Clare of no difference in F vs NF, whichcan be seen clearly from age 5, where no mouth-rinse benefits had taken place.
The Mid-Western Health Board study of 1997 concludes that:
36
DRAFT
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 5: Mean DMFT for 5, 8, 12 & 15 year olds in Limerick, 1997
“An even greater improvement in oral health could be achieved across theMid-Western Board region by improving the effectiveness of existing waterfluoridation schemes, as well as ensuring that, where feasible, other schemesare fluoridate.”94
The North Eastern Health Board Oral Health of Children and Adolescents 1995 study,directed by the Oral Health Service Research Centre, University College Cork, also high-lighted dramatic improvements in decay reduction, “due to the introduction of water flu-oridation following the Health (Fluoridation of Water Supplies) Act 1960”.95 Combinedresults for the three areas, Cavan & Monaghan, Louth, and Meath, highlight differencesbetween the F versus NF areas, across all four age groups (5, 8, 12, 15 year olds) of, onaverage 19%, as can be seen below in figure 8 on page 39.
However these DMFT differences are not distributed evenly across the four age groups.The percentage differences for the four age differences between F versus NF as per chart7, are as follows; 5 year olds (33% difference), 8 year olds (No difference), 12 year olds(25% difference) and 15 year olds (18% difference).
And again, as per the Mid-Western Health Board study, the DMFT differences be-tween F and NF areas are not distributed evenly across the 3 areas studied. Just asin the case of the County Clare anomaly in the Mid-Western study, the North Easternstudy throws up significant anomalies that are not obvious when only the aggregated re-sults are assessed. Of the three areas researched (Cavan/Monaghan, Louth and Meath),the difference in DMFT between F and NF is most pronounced in the Louth area, ascan be see in figure 9 on page 39.
Smaller advantages between the F and NF areas are exhibited in the County Meatharea, as per figure 10 on page 40, where the differences between the four age groups areas follows; 5 year olds (29%), 8 year olds (no difference), 12 year olds (12%), and 15 year
37
DRAFT 0.5
1
1.5
2
2.5
3
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 6: Mean DMFT for 5, 8, 12 & 15 year olds in Clare, 1997
0
0.5
1
1.5
2
2.5
3
3.5
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 7: Mean DMFT for 5, 8, 12 & 15 year olds in Tipperary, 1997
38
DRAFT 0
0.5
1
1.5
2
2.5
3
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 8: Mean DMFT for 5, 8, 12 & 15 year olds in the NEHB, 1995
0
0.5
1
1.5
2
2.5
3
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 9: Mean DMFT for 5, 8, 12 & 15 year olds in Louth, 1995
39
DRAFT
0
0.5
1
1.5
2
2.5
3
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 10: Tooth Decay in 5, 8, 12 & 15 year olds in fluoridated and non-fluoridatedareas in Co. Meath
olds (28%).However, in the Cavan &Monaghan statistics, it can be seen that there is no significant
difference in the DMFT in F versus the NF areas, and in fact, the DMFT is LOWERin the non-fluoridated area for 15 year olds. (see figure 11 on page 41)Surprisingly, the report fails to acknowledge this conflicting DMFT evidence, or ad-
dress the reasons why these results may have been achieved. In addition to not acknowl-edging the results, the report actually states that “in all areas of the North EasternHealth Board tooth decay levels are lower in children with fluoridated domestic watersupplies,”96 which considering the results above for Cavan/Monaghan, is not a whollyaccurate summation of the results, and without detailed knowledge of the individualarea results, could be considered misleading.The North Eastern Health Board report of 1995 concludes that:
“An even greater improvement in oral health could be achieved across thewhole region by improving the effectiveness of existing water fluoridationschemes, as well as ensuring that where feasible, other schemes are fluoridated”.97
Differences in DMFT scores were also found in The Southern Health Board (SHB) OralHealth of Children and Adolescents 1995, directed by the Oral Health Service ResearchCentre, University College Cork.98
The results from the SHB study, as displayed in figure 12 on page 42, show differencesbetween F versus NF areas of 52% for 5 year olds, 40% for 8 year olds, 27% for 21 yearolds and 34% for 15 year olds. The report concludes that:
“An even greater improvement in oral health could be achieved across theSouthern Health Board region by improving the effectiveness of existing water
40
DRAFT
0
0.5
1
1.5
2
2.5
3
3.5
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 11: Tooth Decay in 5, 8, 12 & 15 year olds in fluoridated and non-fluoridatedareas in counties Cavan and Monaghan
fluoridation schemes, as well as ensuring that where feasible, other schemesare fluoridated”.99
In his presentation to the committee Dr. Gerard Gavin stated that there is a need toassess “are there valid comparisons we can make outside Ireland?” In addition to theresults of the Dublin-Glasgow study of 1992 (which was analysed in a previous section),according to Dr.Gavin “one of the most telling studies of all. . . was that carried outbetween the North Western Health Board and the Health Board of Northern Ireland in1998–9”100
“What we find is that tooth-decay levels in 15 year olds in fluoridated areaof Donegal was 2.2 and for 14 year olds in the Western Health Board inNorthern Ireland (which is not fluoridated) was 4.52. These two were almostexactly adjacent to each other. That is a 51% difference in the decay levelsbetween both areas.”
Given the difficulties already outlined with the Dublin–Glasgow 1992 study, and bear-ing in mind the variability of the results presented in comparing fluoridated and non-fluoridated areas in this section, we ought to be careful in using the above sample statis-tics as conclusive evidence of water fluoridation’s effectiveness. Also, a caveat entered byDr. Whelton and Professor O’Mullane’s report on ‘The Effectiveness of Water Fluori-dation in Ireland’,101 may indeed justify categorising these results as merely ‘tentative’,where the report claims that:
“The comparisons with Northern Ireland should be interpreted with cautionas the examiners are trained and calibrated in a slightly different way tothose in the Republic of Ireland”
41
DRAFT
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5 Year Old 8 Year Old 12 Year Old 15 Year Old
DM
FT
FluoridatedNon-Fluoridated
Figure 12: Tooth Decay in 5, 8, 12 & 15 year olds in fluoridated and non-fluoridatedareas in the SHB 1995
Overall, the evidence presented in this section, based on research conducted by thevarious health boards in Ireland over the past 40 years, has shown statistical differencesin decay in fluoridated areas versus non-fluoridated areas. However, there are varyingresults, with differences not evenly distributed in geographical areas, nor over age groups.In some areas, there is no statistical difference in decay in fluoridated and non-fluoridatedareas, and there exist instances where the level of decay is lower in the non-fluoridatedareas versus the fluoridated equivalent.
6.8 Decay Free Children in Fluoridated and Non-fluoridated Areas.
One of the statistics that acts as a measure of the differences in oral health in fluoridatedversus non-fluoridated areas, and therefore needs a brief mention, is the percentage ofthe population with ‘no caries’ experience.
Just as in the various health board studies cited above, where there is generally lowerlevels of dental decay in fluoridated areas versus non-fluoridated areas, it follows thatthere should also be more people in the fluoridated areas without any traces of dentalcaries, than in non-fluoridated areas. That is, there should be a higher percentage of theage-group population who are “Decay-Free” in fluoridated areas.
The 1984 Children’s Dental Health in Ireland study compared the percentage of chil-dren with no known caries experience (caries free) in each of the four age groups, andfound that in fluoridated areas there was a higher percentage of each age group who had“no known caries experience”, thereby indicating a statistical benefit from fluoridation.The results are displayed below in figure 13 on page 44.102
Similar differences can be seen in the statistics from recent individual Health Boardstudies, such as theMid-Western Health Board Survey 1997.103 In this study for example,
42
DRAFT
it can be seen that for 5 year olds, 62% of these children in fluoridated areas have noknown dental decay, versus 45% of the 5 year old children living in non-fluoridatedareas. The percentage difference in fluoridated areas versus non-fluoridated appears todecrease as the children grow older, with 21% of the 15 year old children in fluoridatedareas showing no decay, versus 18% in non-fluoridated areas as in figure 14 on page 44.
However the consistency of these trends in Ireland comes into question when studyingin World Health Organisation quoted statistics for Ireland from a study published in1996.104
It is clear from this WHO study that in 12 year old children in Ireland, there is a higherpercentage of children in ‘non’-fluoridated areas who have no known caries, than in thefluoridated area. In the fluoridated areas of the study, 42% of the 12 year old populationhad ‘no decay’, compared to 44% of the 12 year old population in the non-fluoridatedarea (figure 15 on page 45).
This reversed trend in percentage of decay free children in the 1996 study, where thereare more children in Non-fluoridated areas without dental caries, appear to contradictthe results of the health board studies.
6.9 International Studies which have Shown Little Benefit from Water
Fluoridation
Although there are many international studies showing the benefits of water fluoridation,it must be acknowledged that research going back as far as the 1950s up to the presentday, has presented contrary results, consistently highlighting that there is ‘no benefit’to be derived from water fluoridation. In addition, the studies in the US in the 1945s,on which the rationale for water fluoridation was based, have been heavily criticised forcontaining serious flaws and inconsistencies in well documented monographs by the lateDr. Philip Sutton (1960, 1980, 1996)105, Dr. Ziegelbecker (1981106, 2000107), ProfessorPaul Connett (2000)108 and Dr. John Yiamouyiannis (1993).109 These criticisms havebeen disputed by proponents of water fluoridation. In his presentation to the committee,Professor O’Mullane referred to the initial trials showing that water fluoridation waseffective as “very carefully conducted controlled studies”.110
Detailed below is just some of the much published international evidence that hasled many to conclude that there is no oral health benefit to be derived from waterfluoridation programmes:
In 1953 dentist Donald J. Galagan conducted a study in Arizona. The results as pub-lished in the Journal of the American Dental Association found no significant differencein tooth decay rates between high-and low fluoride areas.111
In 1955 Dr Eugene Zimmerman from the National Institute of Dental Research in theUS reported on a 10-year study of Barlett, Texas (8 parts per million) and Cameron,Texas (0.4 parts per million). The report published in the Journal of the AmericanDental Association stated that “no significant difference was found between the Barlettand Cameron residents”.112
In 1962, Dr. Edward A. Sweeny and co-workers at the Harvard School of DentalMedicine reported that fluoride had little effect on tooth decay rates on laboratory
43
DRAFT 0
10
20
30
40
50
60
70
5 Year Old 8 Year Old 12 Year Old 15 Year Old
% w
ith N
o kn
own
Car
ies
Exp
erie
nce
FluoridatedNon-Fluoridated
Figure 13: Percentage of Children with no known caries experience, 5, 8, 12, 15 year old- 1984
10
20
30
40
50
60
70
80
5 Year Old 8 Year Old 12 Year Old 15 Year Old
% w
ith N
o kn
own
Car
ies
Exp
erie
nce
FluoridatedNon-Fluoridated
Figure 14: Percentage of Children with No known caries experience, 5, 8, 12, 15 yearolds - MWHB 1997
44
DRAFT
0
10
20
30
40
50
60
70
5 Year Old 12 Year Old
% w
ith N
o kn
own
Car
ies
Exp
erie
nce
FluoridatedNon-Fluoridated
Figure 15: Percentage of Children with No Caries – 5 and 12 year olds – WHO 1996
rats.113 In 1971 Hardwick and Bunting of the Turner Dental School in Manchester studiedthe effect of fluoridation on tooth decay in rats. Their findings as published in the Journalof Dental Research said, “Changes in the number of lesions were not significant with 1or 2 part per million fluoride supplementation”.114
In one of the largest studies investigating the effect of naturally occurring calciumfluoride in reducing tooth decay, in 1972 Dr. Yoshitsugu Imai of the Tokyo Medical andDental University examined more than 20,000 students. The results of the study founda higher percentage of students with tooth decay in areas of fluoride levels of 0.4 partsper million or more in the drinking water than in areas with 0.2 to 0.39 parts per millionin the drinking water.115
Research by Colquhoun (1987)116 in New Zealand concluded that child dental de-cay differences are not closely related to the presence or absence of water fluoridation.Official census information suggests that dental health differences could be related todemographic, especially socio-economic factors. There was no significant difference intooth decay between fluoridated and non-fluoridated areas, as evidenced in the examplebelow in Table 7 on page 46
In 1987 the Journal of the Canadian Dental Association published an article whichsuggested that that water fluoridation wasn’t doing the job that dentists had been claim-ing it could do. It pointed out that “survey results in British Columbia with only 11%of the population using fluoridated water show lower DMFT rates than provinces with40–70 per cent of the population drinking water” and “school districts recently reportingthe highest caries-free rates in the province were totally unfluoridated”.117
In 1989 Hildebolt et. al used caries data on 6,584 school children in a study of secondand sixth graders drinking optimally and sub-optimally fluoridated water in Missouri.“In the total sample, there was no significant differences between those children drinkingoptimally fluoridated water and those drinking sub-optimally fluoridated water”.118
45
DRAFT
Table 7: New Zealand tooth decay in fluoridated and non-fluoridated areas
Area Fluoridation Status No. of Students DMFT
Christchurch Non-Fluoridated 14,166 3.05
Hamilton Fluoridated 8,065 3.2 (Higher)
Dunedin - 3,955 2.9 (Lower)
Palmerstown Non-Fluoridated 3,771 3.15 (Higher)
Auckland Fluoridated 39,404 2.95 (Lower)
Wellington Fluoridated 17,368 2.8 (Lower)
The study by Yiamouyiannis (1990) was based on an analysis of the results of researchconducted by the US National Institute of Dental Research (NIDR). This was one ofthe largest modern surveys of its kind. Data from 39,207 children aged five to seventeenyears from 84 areas in the USA showed that the number of decayed, missing and filledteeth in children who had been fluoridated all their lives was no fewer than those whohad been brought up in non-fluoridated. Of the 84 areas, 27 had been fluoridated for 17years or more (F), 30 had never been fluoridated (NF), and 27 had only been partiallyfluoridated or fluoridated for less than 17 years (PF). The average number of decayed,filled, and missing teeth per child (DMFT) was 1.96 in the F areas, 2.18 in the PF areas,and 1.99 in the NF areas.119
A sub-set of this data was re-examined again by Carlos and Brunelle (1990) using amore sensitive barometer of tooth decay (DMFS, decayed, missing, filled surfaces) andfound a 19% difference in the two communities. This is less than half a tooth.120 Amassive study conducted on 400,000 children in India by Teotia in 1994 was designed toinvestigate the essentially or otherwise of fluoride and calcium nutrition in the preventionand control of dental caries. The findings of this comprehensive epidemiological study,performed during the period 1963–1993, indicate that dental caries was ‘caused’ by highfluoride and low dietary calcium intakes, separately and through their intersections.Dental caries was most severe and complex in calcium-deficient children exposed tohigh intakes of endemic fluoride in drinking water. The report concluded that the onlypractical and effective public health measure for the prevention and control of dentalcaries is the limitation of the fluoride content of drinking water to<0.5ppm, and adequatecalcium nutrition (dietary calcium > 1g/day).121
Assessing the studies proving the dental benefits of water fluoridation, Dr. JohnYiamouyiannis acknowledges that there has never been a ‘double-blind’ study showingthat fluoridation works. This type of study refers to research in which neither examinernor patient know who is in the test group and who is in the control group. Accordingto Dr. Yiamouyiannis “this type of study is necessary to eliminate examiner-patientbias”.122
Echoing Dr. Yiamouyiannis’s claims, the recent York University Review (2000), statedthat in their search for high quality studies showing the benefits of water fluoridation:“no randomised controlled trials of the effects of water fluoridation were found”.123
46
DRAFT
6.10 Dental Decay in Adults and the Theory of ‘Delayed Eruption’
The evidence presented so far has been based on the effects of water fluoridation onchildren aged from 5 to 15. There has been no analysis of the effects of water fluoridationon adults. One of the reasons why it is necessary to at least acknowledge the decay ratesin adults, is because it has been proposed by some researchers that the suggested dentalbenefits of water fluoridation disappears after the early teen years.124 However accordingto O’Mullane et. al (1996):
“Because of the unreliability of assigning a cause for missing teeth amongadults, particularly older adults, the DMFT index for caries is not as reliablea measure of dental caries as it is for children, hence, interpretation of DMFTdata for adults is difficult”.125
Making allowances for this difficulty with interpreting the DMFT results of older people,statistics quoted by the World Heath Organisation in 1995 for 35–44 year old adultsin Ireland show DMFT levels with no statistical difference for fluoridated versus non-fluoridated areas. Those 35–44 year olds living in fluoridated areas had a DMFT of18.9, whilst those in the non-fluoridated area had a DMFT of 19.0, which is virtuallyidentical.126
In his presentation to the committee Dr. Limeback introduced the theory of “delayederuption” as a possible reason why we see lower decay rates in children living in fluori-dated areas, but these statistical differences dissipate, and even out over time resultingin no difference in F versus NF areas as the individuals moves into adulthood:
“One of the things that fluoridation studies failed to investigate years agowas the effect of fluoride ingestion. Now they have discovered, including workthat I have done, that fluoride ingestion delays tooth eruption. It is quiteevident that fluoride ingestion has an effect on the development of teeth.When tooth eruption is delayed, that delays decay. That means that about20 to 30 per cent of the 50 per cent reduction that was claimed back in the1950s could have been due to a simple delay in tooth eruption”.127
A number of international studies have concluded that fluoride ingestion delays tootheruption and may simply delay tooth decay in fluoridated areas, resulting in ‘temporary’lower thrift results in these fluoridated areas.128 129 130 131
6.11 What would happen if we stopped water fluoridation in Ireland?
In defining Ireland’s future policy in relation to water fluoridation, one of the mostimportant variables that should be considered when shaping that policy, is an awarenessof the possible oral health effects of stopping the fluoridation of the water supplies(i.e. a definite decrease in dental fluorosis versus a possible increase in dental caries).Although the consequences of discontinuation of water fluoridation was not addressedat the committee presentations by Dr. Gavin, or Professor O’Mullane, the AmericanDental Association has asserted that:
47
DRAFT
“Dental decay can be expected to increase if water fluoridation in a commu-nity is discontinued for one year or more, even if topical products such asfluoride toothpaste and fluoride rinses are widely used”.132
Offering an opposing viewpoint however, in his presentation to the committee Dr. Lime-back asserted that:
“Overall, world-wide, the numbers are so minor in comparison that stoppingwater fluoridation would make little difference. It has been done four or fivetimes over the world. What is noticed is the decrease in dental fluorosis, butan increase in dental decay is not seen”.133
The York report looked at the evidence in relation to the effect of discontinuing waterfluoridation, with the evidence presented as follows:
“Of 22 analyses of stopping water fluoridation, 14 found the direction of as-sociation to be negative (that stopping water fluoridation led to an increasein caries in the previously fluoridated area compared to the never-fluoridatedarea). However only eight of these studies provided a measure of the signif-icance of this association. Four of these analyses found that stopping waterfluoridation had a statistically significant effect at the 5% level, while theother four did not. Eight analysis found the direction of association to bepositive (that stopping had not led to increases in caries in the previouslyfluoridated areas)”.134
Dr. Limeback suggested that if Ireland did stop fluoridating the water and there hap-pened to be an increase in dental caries, it would not be measurable or statisticallysignificant:
“In Ireland decay rates are very low, even in non-fluoridated areas. If thefluoridation equipment was shut down tomorrow in Ireland, at ‘most’ onewould see one extra filling for every fourth person.”“Turning off the fluoride taps’ would not cause massive decay. Even if
it did increase decay rates, they could not be measured. The number offillings that would result would be so minor that it could not be measuredstatistically.”
Dr. Limeback suggests that even if decay rates did increase, at most, it would resultin a 0.25 increase in DMFT scores (one filling for every fourth person). As the possiblehealth effects of discontinuing water fluoridation in Ireland is such an important issue,it is necessary to detail some of the research that has looked into this area, focusing onthe results of studies in Finland, the Former East Germany, Cuba and Canada.
6.11.1 Former East Germany
In contrast to the anticipated increase in dental caries following the cessation of waterfluoridation in the cities Chemnitz (formerly Karl-Marx-Stadt) and Plauen, a significantfall in caries prevalence was observed. This trend corresponded to the national cariesdecline.135
48
DRAFT
6.11.2 Finland
Water fluoridation in Kuopio, Finland, was stopped in 1992. In one previous study,no increase in caries was found in Kuopio 3 years after the discontinuation of waterfluoridation.136 In 1992, 1995 and 1998 independent random samples of all children aged3, 6, 9, 12 and 15 years were drawn in Kuopio and Jyvaskyla. Again in the studypublished in November 2000 no increase in caries was found, with the conclusion beingthat “the fact that no increase in caries was found in Kuopio despite discontinuation ofwater fluoridation and decrease in preventive procedures suggest that not all of thesemeasures were necessary for each child”.137
6.11.3 Canada
A study shows that caries rates did not increase when communities stopped fluoridat-ing water in British Columbia, Canada, following a baseline survey after a period ofthree years. The prevalence of caries (assessed in 5,297 children, grades 2, 3, 8, 9) de-creased over time in the fluoridation-ended community while remaining unchanged inthe fluoridated community.138
6.11.4 Michigan US
Those advocating water fluoridation have claimed that even a break of a year in waterfluoridation will affect dental caries. However, a study from February 2000 suggests acontrary viewpoint. Durham, NC, fluoridated since 1962, had an 11 month cessationof fluoridation between September 1990 and August, 1991. It was concluded that therewas no effect on caries (whilst concluding that dental fluorosis is sensitive to even smallchanges in fluoride exposure from drinking water).139
6.11.5 Cuba
This study aimed to analyse the effect of cessation of water fluoridation in La Salud(Province of Hababa) in 1990. In contrast to an expected rise in caries prevalence,DMFT and DMFS values remained at a low level for the 6 to 9 year olds and appearedto decrease for the 10/11 year olds. In the 12/13 year olds there was a significantdecrease, while the percentage of caries-free children of this age group had increased.140
Although not specifically addressing the issue of what might happen to caries levels ifthe water fluoridation programme was halted, The Royal College of Physicians report on“Water Fluoridation and Public Health” suggests that when caries levels are already low,an intervention programme such as water fluoridation may be susceptible to decreasingmarginal returns:
“The general decline in prevalence of dental caries in the past 20 years amongchildren from all areas of Ireland could be a contributing factor to the appar-ent reduced effectiveness of water fluoridation when expressed in percentageterms.
49
DRAFT
Any preventive measure agent will be apparently less effective when the con-dition becomes less prevalent”.141
The final section will address some of the possible alternatives to water fluoridation inthe fight against caries, as well as establishing who benefits from water fluoridation.
6.12 Who Benefits Most from Water Fluoridation, and what possible
alternatives are there for oral health care?
When water fluoridation was introduced in the 1960s it offered a substantial increase indaily consumption of fluoride, where daily ingestion levels had previously been relativelylow. However, total fluoride exposure has increased over recent years, particularly inindustrialised nations.142 When water fluoridation was introduced in the 1960s, in addi-tion to the low standards in general and oral health that existed at the time, there wereno fluoridated toothpastes on the market (fluoridated toothpaste was only introducedto Ireland in the early 1970’s).
Today 95% of all toothpastes contain fluoride, and have been credited with reducingdental decay in non-fluoridated regions and countries.143 In judging the effectivenessand efficiency of using the public piped water supplies to distribute fluoride to the entirepopulation, we need to ask whether the whole population actually needs this additionalfluoride source, above that derived from fluoridated toothpaste? Also, does the entirepopulation actually derive a benefit from water fluoridation?
Recent comments from the Department of Health suggests that this additional sourceof fluoride, above that received in fluoridated toothpaste, is ‘not’ needed by a large partof the population. Dr Gerard Gavin recently commented on this issue:
“We would not deny that people in more affluent areas do not need to receivefluoride in their water because of the low levels of disease. But dental decay,like many illnesses, affects socially excluded people predominantly”.144
Dr. Gavin has inferred that water fluoridation should be maintained to help the oralhealth of those in the lower socio-economic classes and socially-excluded classes, as thesesegments of the population do not participate in the oral health services, and use littletoothpaste, if any at all:
Dr. Gavin:“The issue in relation to oral heath for people who are sociallyexcluded is that they do not participate. Whether one employs legions ofdentists or not is immaterial as these people do not participate in healthservices.”
Chairman: “Or buy toothpaste?”
Dr. Gavin: “Or buy toothpaste, or at least practice low utilisation. Thisis why fluoridation is still very important for Ireland. We know from theCombat Poverty Agency that we still have quite a substantial number ofour population, particularly of our children, living in poverty, despite the so-called ‘Celtic Tiger’. That is something worthy of significant reflection”.145
50
DRAFT
It has not been ascertained whether there is unequivocal evidence that the lowersocio-economic classes and socially excluded, do not use toothpaste. Also, regarding‘low utilisation’, again it is not clear if this refers to the amount of toothpaste used,which should only be a pea-sized amount.
Speaking in response to the question by reporter Robert Jordan on TV3’s 20/20,on “whether people who used toothpaste twice a day, and use an adequate amount oftoothpaste, do they need water fluoridation?” Dr. Gavin also commented;
“Well that is the question right, but our evidence is that in this country/that our tooth-brushing habits are way behind European norms, Europeanstandards, and you’ve also got the issue of compliance”.146
Therefore, the logic being extended by the Department of Health infers that anyonewho brushes their teeth with fluoridated toothpaste twice a day does not need fluoridatedwater. However, due to low standards in oral care practices by some pockets of the Irishpopulation, we should continue to fluoridate the water for the benefit of this populationsegment. Minister for Health Micheal Martin has pointed out that “surveys show forexample that 50% of all adolescent boys in this country at this very point in time don’tbrush their teeth more than once a day, and in some cases not at all”.147
However, in their various oral health surveys, the health boards have investigatedthe brushing habits of children, with consistent results. For example The Mid-WesternHealth Board Survey of 1997 stated; “most 8 and 15 year olds brush their teeth at leasttwice a day”.148 Similar results were found in the North Eastern Health Board Survey1995149 where 70% of the 8 and 15 year olds brushed their teeth twice a day. Only 3%of 8 year olds, and 4% of 15 year olds brushed their teeth “less than once a day”.
Dr. Limeback has acknowledged that dental decay afflicted the lower socio-economicclasses to a greater extent, but suggested a simple solution to eradicating these lowstandards in oral care in pockets of the population:
“Obviously the money would be much better spent targeting the poor andthe underprivileged who carry the burden of most dental decay”.150
Reports in Ireland have highlighted that the waiting lists for dental care via the publichealth service are excessively long. Many children have an average wait of five and aquarter years for an appointment for an orthodontist. Figures for other health boardregions include a wait of between four and five years in the Midlands, Mid-Westernand Southern Health Boards. According to the media report, “the waiting times re-late to the time it takes for children whose parents’ cannot afford treatment for theirchildren’s teeth’.151 Therefore, waiting times such as these will obviously contribute sig-nificantly to the lack of ‘participation’ in the health services by the lower socio-economicclasses/socially excluded mentioned above.
This issue of spending the resources currently being used to fluoridate, to targetthose who need it most by educational programmes has been addressed by ProfessorO’Mullane:
51
DRAFT
“The suggestion is, as 1 understand it, that if we manage to give good dentalhealth education, advise our children to stop eating sweets and get them tobrush their teeth more thoroughly twice a day, we would succeed. I havebeen involved in health promotion for 30 years. Unfortunately, the evidenceis that it is singularly unsuccessful. The data now suggests that despite ourefforts over many years with regard to diet and dental health education, weare not succeeding. The sugar usage patterns in this country are now morecarcinogenic [sic] than they were in the past.”152 (I think this should read‘cariogenic’1)
The reasons why these oral health education programmes have not been successful inimproving the oral health practices in their targeted audiences consistently over a 30year period, or suggestions on how these educational programmes could be improved toachieve their goals in the future, were not discussed at the committee presentations.However, it should be pointed out that the above reference to ‘sugar usage patterns’
now being more cariogenic than they were in the past, conflicts with the evidence fromO’Mullane et. al 1996, and discussed in the previous section, where it was outlined thatsugar consumption per capita has been decreasing in Ireland. Also, to re-iterate a pointdiscussed in a previous section, comparative to our European neighbours, Ireland’s percapita sugar consumption appear to be relatively low.
Dr. Gavin mentioned to the committee that instead of water fluoridation, some Eu-ropean countries sell salt that has fluoride levels present, thereby inferring that this‘systemic’ consumption of fluoridated salt acts as an alternative to the ‘systemic’ con-sumption of fluoride in Irish water. The Department of Health has added that “inEurope, the most common method for the distribution of fluoride to the population isthrough fluoridated salt”.153
However, considering that 95% of toothpastes in Ireland are fluoridated, and we stillappear to have problems of ’compliance’ amongst certain pockets of the population inbrushing their teeth, which is a standard common-place oral care procedure, it has notbeen made clear how fluoridated salt mimics water fluoridation (i.e. it was not madeclear ‘if’ or ‘how’ ‘compliance’ is achieved in relation to consumption of fluoridatedsalt in these other countries). Therefore it must be presumed that compliance in thepurchase or consumption of fluoridated salt is not mandated by the governments in thesecountries (France, Switzerland, Belgium and some parts of Germany), and fluoridatedsalt is merely an ‘extra option’, no different than the fluoridated mouthwashes readilyavailable in the Irish market, available for anyone who wishes to purchase them.Further to the above issues, there is a need to address some more fundamental aspects
of the monitoring of this intervention programme from a dental caries perspective, with aneed for an outline of what measures should be adopted in making a decision to continue,or not, the water fluoridation programme in Ireland.One of the main questions that needs to be asked is: will Ireland always need water
fluoridation? Also, if a decision to “terminate is based on oral health benchmarks, ratherthan general health grounds”, what should these oral health benchmarks be?
1causing tooth decay
52
DRAFT
Dr. Maire O’Connor, co-author of the Royal College of Physicians report on “WaterFluoridation and Public Health” recently addressed the issue of when Ireland could stopfluoridating:
“I would hope in the future as I’ve said before, that we won’t need such aprogramme because we won’t have dental caries”.154
However no country has a situation of ‘no caries’. Although Ireland does not ranktop of the oral health charts in Europe, statistically there is little difference between thetop countries (who don’t fluoridate the water) and Ireland, with Ireland’s dental carieslevels already low.
As mentioned in a previous section, the Royal College of Physicians report claimsthat when caries levels are already low, as they are in Ireland, “any preventive measureagent will be apparently less effective when the condition becomes less prevalent”.155
This would suggest that having an objective of “no dental caries” as the main bench-mark for deciding to cease the water fluoridation programme in Ireland is, quite simply,statistically unattainable, and will never be achieved.
Also speaking about Ireland’s future need for water fluoridation, Dr. Gavin has statedthat:
“Our evidence is that in this country that our tooth-brushing habits are waybehind European norms, European standards, and you’ve also got the issueof compliance. As I was saying, at some time in the future if we can changeboth our eating habits and also our prevention habits in terms of how welook after our teeth, then we may not need water fluoridation in the future”.
As we have seen in the above chapter, Ireland’s diet is improving, and our sugarconsumption patterns are one of the lowest in Europe. Considering the issue of improvedbrushing habits and “compliance”, for example, the above chapter has also explored thatthe issue of ‘compliance’ for tooth brushing in Ireland is a statistically insignificant issuethat could be addressed in a more targeted approach, considering that only a statisticallysmall percentage of the population fall into this category.
What needs further clarification and exploration is whether ‘significant’ oral care im-provements actually are still achievable in Ireland in the future. This has not beendemonstrated unequivocally. Based on this knowledge, if there actually still is room forimprovement, what is needed is a full understanding of whether water fluoridation canin any way aid this process. In addition, there needs to be a clear understanding of whoshould set, and what ‘realistic’ benchmarks should be adopted in this process.
6.13 Summary and Conclusions
Dental decay has been decreasing in both the fluoridated and non-fluoridated areas inIreland, at similar rates to the general decrease in dental caries that can be seen inmost industrialised countries around the world (both fluoridated and non-fluoridatedcountries). Many international studies and experts attest that this general world-wide
53
DRAFT
decrease in decay is due to the improvement in diet (such as reduction in sugar con-sumption as evidenced in Ireland), use of antibiotics, fluoridated toothpaste, improvedawareness of oral health, etc.The Royal College of Physicians of Ireland has also concurred that “the general decline
in the prevalence of dental caries in both fluoridated and non-fluoridated areas may reflectthe widespread use of fluoride supplementation, especially fluoride tooth-pastes togetherwith factors such as the changing patterns of sugar consumption, changes in oral hygienepractices, dental screening and increasing awareness of the importance of oral health”.As Ireland has also benefited from the same variables that non-fluoridated countries
attribute to the success of their dental decay improvement, and Ireland’s rate of decaydecrease has mirrored what has happened in other non-fluoridated countries, this makesquantifying the contribution made solely by water fluoridation in Ireland a very difficulttask.During the period of water fluoridation, Ireland’s consumption per capita of sugar has
decreased by 20%. With sugar being the main cause of dental decay, this 20% decreasein sugar consumption must account for about 20% of the 70% reduction in dental decayseen since the reduction in dental decay.Ireland ranks 8th in a table of highest consumption of sugar per capita from a sample of
14 European countries. Considering that we are the only country fluoridating the watersupplies, and we do not have a high consumption of sugar per capita when compared tothe rest of Europe, we rank 6th in tooth decay statistics in Europe.The decrease in dental caries in Ireland can thus be attributed to many factors other
than water fluoridation. Therefore water fluoridation cannot be credited as the ‘sole’ or‘main’ factor in the improvement in oral health in Ireland.The York review of the literature on dental benefits claims that the research proving
the benefits of water fluoridation is not of high quality and limited quantity, and thatthe benefits have been overstated. It claims a 14.6% improvement in decay reductionfrom water fluoridation.Many international peer reviewed studies have proven that there is no benefit to be
derived from water fluoridation, with decay rates being similar in both fluoridated andnon-fluoridated communities.However, numerous studies conducted by the various health boards in Ireland on the
age groups 5 year old, 8 year old, 12 year old, and 15 year old, show a difference inrates of decay in fluoridated communities versus non-fluoridated communities. Howeversome of these results show no difference in decay between fluoridated and non-fluoridatedareas, and some areas have lower decay in non-fluoridated areas.The Department of Health have confirmed that most of the population of Ireland do
not actually need water fluoridation (ie. anyone who brushes their teeth twice a day withfluoridated toothpaste does not need water fluoridation). However due to the fact thatstudies show that some children do not brush their teeth regularly, it has been proposedthat we should continue to fluoridate the water for this niche audience.Educational programmes in Ireland have been unsuccessful in helping this target au-
dience improve their oral care habits (i.e. successive educational programmes have failedto succeed in getting a minority of children to brush their teeth twice a day). It has
54
DRAFT
been suggested that if the oral care habits of this target audience could somehow beimproved there would be no need to continue with the fluoridation of the public pipedwater supplies in Ireland.There is evidence that the difference in tooth decay in fluoridated and non-fluoridated
areas may be due to the fact that fluoride has been shown to cause “delayed eruption”in teeth. Therefore it is possible that teeth in fluoridated areas in a certain age groupmay not have been exposed to sugar for the same duration as those of a similar agein non-fluoridated areas. This would naturally result in a lower DMFT result in thefluoridated area than the non-fluoridated area.Studies show no difference in the decay rates in adults (35–44 year olds) in Ireland
when comparing those living in fluoridated areas versus non-fluoridated areas.The evidence suggests that there would be no significant increase in dental caries if
the practice of water fluoridation ceased. Numerous international studies have shownthat there is
- An increase in dental caries,
- A decrease in caries
- No change—no increase in dental caries.
In comparison to countries with a similar diet to Ireland, such as Scotland, wherethere is no water fluoridation, there is little evidence to conclude that there would bean increase in the dental decay rates in Ireland if water fluoridation was to be stoppedin Ireland.
7 Health Effects
7.1 The Legitimate Scientific Controversy
Fluoridation became mandatory in Ireland in the early 1960s and an investigation thenby the Fluorine Consultative Council declared that fluoride was safe and had no adversehealth effects. However, nearly forty years on, the scientific climate has changed consider-ably. Since then, there have been innumerable studies, investigations and developmentsin artificial water fluoridation. The conclusions in many cases are contradictory but it isimportant to consider all aspects of these developments, both pro and anti-fluoridation.A most comprehensive assessment of the health effects of water fluoridation is containedin the York Review.
7.2 The York Review
The York Review156, commissioned by the National Health Service in the United King-dom (U.K.), published its conclusions in September 2000. This review claimed to bea full assessment of worldwide scientific literature into the effects of water fluoridation.Soon after publication in the British Medical Journal, Professor Trevor A. Sheldon,
55
DRAFT
Chairman of the York Review’s Advisory Group, stated “the review was exceptionalin this field in that it was conducted by an independent group to the highest interna-tional scientific standards and a summary has been published in the British MedicalJournal”.157 However, the conclusions drawn from this review are as controversial as thewhole issue of water fluoridation.
Professor Sheldon continued by expressing his growing concerns that pro-fluoridationgroups had spun the conclusions of this independent report. They were now misleadingthe public.“It is particularly worrying then that statements which mislead the publicabout the review’s findings have been made in press releases and briefings by the BritishDental Association, the British Medical Association, the National Alliance for Equityin Dental Health and the British Fluoridation Society”.158 Professor Sheldon ended hisletter to the press by concluding, “the review team was surprised that in spite of the largenumber of studies carried out over several decades there is a dearth of reliable evidencewith which to inform policy. Until high quality studies are undertaken providing moredefinite evidence, there will continue to be legitimate scientific controversy over the likelyeffects and costs of water fluoridation”.159
In Ireland, despite this “dearth of reliable evidence”, fluoridation continues. There aregrowing public concerns of the health effects of artificial water fluoridation. Therefore, itis important to consider all aspects, both pro- and anti-fluoridation, of this “legitimatescientific controversy”.
7.3 The “Legitimate Scientific Controversy”
The Department of Health offers reassurance that, “major reviews of the evidence byleading medical scientists have shown time and time again that the use of fluoride indrinking water at one part per million is safe to human health”.160 Dr. Gerard Gavin(former Chief Dental Officer, Department of Health) lists, “. . . organisations that sup-port water fluoridation, such as the World Health Organisation, the Centres for DiseaseControl and Prevention in Atlanta. . . and the Royal College of Physicians in Ireland,through their faculty of public health”.161 The World Health Organisation (hereafterW.H.O.) regularly cited as endorsing water fluoridation declares that, “fluorine is prob-ably an essential element for animals and humans. For humans, however, the essentialityhas not been demonstrated unequivocally, and no data indicating minimum nutritionalrequirements are available”.162 The York Review also confirmed a similar lack of conclu-sive efficacy; “no randomised controlled trials to the effects of water fluoridation werefound”.163
In Ireland, as regards the general health of fluoridated communities, a clause in theHealth (Fluoridation of Water Supplies) Act requires that the Minister of Health carryout health surveys.164 Despite this legislation, the Department of Health and successivehealth ministers have never carried out a health study into the possible health effectsof water fluoridation. Dr. Gavin, on behalf of the Department of Health, confirmedthis fact to the Dail Committee on Health and Children.165 Though not an independentreview of fluoridation in Ireland, the Royal College of Physicians, Faculty of PublicHealth, published a report (“Water Fluoridation and Public Health”) in 1999. This
56
DRAFT
faculty report reaffirmed the status quo; “. . . the data available to date strongly supportthe continuation of the current water fluoridation policies”.166 They expressed concernabout dental fluorosis, “. . . a defect of enamel caused by excess fluoride disrupting thedeveloping enamel prior to tooth eruption”.167 Dr. Gavin agrees that, “dental fluorosisis a side effect of ingesting more than the ideal amount of fluoride”168 and ProfessorDenis 0’Mullane, University College Cork, stipulates that, “we find that approximately50% of the population who reside in fluoridated communities have this very mild, veryquestionable change in the appearance of the enamel”.169 In conclusion, a significantpercentage of the Irish population, who have dental fluorosis, are getting “more than theideal amount of fluoride”.170 This level of fluoride overexposure gives rise for concern.
7.4 Dental Fluorosis
Both proponents and opponents agree on the fact that fluoride overdosing causes dentalfluorosis. However, the nature, the prevalence of this condition and the implicationsfor dental fluorosis sufferers are very much in dispute. There is also disagreement inthe definition of this fluoride disorder. According to the Faculty of Public Health, RoyalCollege of Physicians of Ireland, “. . . dental fluorosis is permanent hypo-mineralisation ofenamel resulting from excess fluoride reaching the developing tooth during developmentalstages”.171 Dr. Geoffrey Smith, Dental Surgeon, argues, “dental fluorosis, no matter howslight is an irreversible pathological condition recognised by authorities around the worldas the first readily detectable clinical symptom of previous chronic fluoride poisoning.To suggest we should ignore such a sign is as irrational as saying that the blue-black linewhich appears on the gums due to chronic lead poisoning is of no significance becauseit doesn’t cause any pain or discomfort”.172 On the other hand, proponents say thatdental fluorosis is “. . . a cosmetic issue, not a health problem”173 and the Departmentof Health classifies this condition under “Aesthetic Effects”.174 Meanwhile, opponentsof fluoridation claim that dental fluorosis is classified as a cosmetic issue in an attemptto lessen its significance.175 However, there is evidence that this condition is not merelycosmetic but, in fact, structural damage: that dental fluorosis results in a variety ofpathological changes in the structure of teeth.176177 Proponents of fluoride do admitthat even teeth with very mild fluorosis are more porous.178 In 1999, Dr. Susheela, etal., performed a study examining fluorosed teeth under a scanning electron microscope.They found, “the scanning electron micrographs of the enamel surface of fluorosed humanteeth show pitted, uneven and rough surfaces. Cracks and fissures were also observedon the enamel surface of fluorosed teeth”.179 After 50 years of fluoridation, the exactmechanism for this fluoride tooth damage is still largely unknown.
7.5 Signs of Dental Fluorosis
The first signs of dental fluorosis2 are seen as fine white lines running across the tooth, thetips of the teeth may appear opaque white. This known as the “snow cap phenomenon”.180
2See http://www.fluoridealert.org/dental-fluorosis.htm
57
DRAFT
In more affected teeth the white lines thicken and are more evident. As the severity in-creases most of the tooth has cloudy white areas with some slight brown discolouration.Next, there is some loss of enamel surface with pitting. This pitting can result in chip-ping off enamel. Eventually in the more severe cases, there is complete loss of enameland major brown staining. Dr. Gerard Gavin summarises, “one gets white spots on theteeth, surface pitting and in severe cases, there is brown staining on the teeth”.181
7.6 Prevalence
Dental fluorosis was described as early as 1916.182 The condition was then known as“mottled enamel“. Dentists expressed concern about the condition commonly referredto as “Colorado Brown Stain”. This condition was linked to areas with significantfluoride levels in the water183
There is growing concern about the increasing number of people with this condition influoridated areas. “More recently, a prevalence of 80.9% was reported in children 12–14years old in Augusta, Georgia, the highest prevalence yet reported in an optimally fluo-ridated community in the United States”.184 In Ireland, the Royal College of Physiciansconcurs, “in recent years concerns have been raised about the increased prevalence ofdental fluorosis in the United States. Mild levels of fluorosis in some children are associ-ated with the ingestion of ’optimally fluoridated’ water”.185 They also admit that “theoptimal level of fluoride intake has yet to be fully determined”.186 In fact, “the mostimportant and widely disregarded fact about dental fluorosis is this: no safe establisheddaily intake exists. . . ”.187
7.7 Dental Fluorosis Levels in Ireland
The levels of dental fluorosis in Ireland are also disputed. Dr. Gerard Gavin estimates,“. . . that dosing at 0.8 to 1 part per million, the Irish standard, gives a 10% risk of mildto very mild dental fluorosis”.188 This figure is estimated using Dean’s Index which isover 60 years old. In addition, Dr. Gavin’s 10% figure also excludes the category called“questionable fluorosis”. A study by Myers showed that this category is associatedwith fluoride levels in water.189 In contrast, Professor O’Mullane quoted a figure of“50% of the population”190 exhibit dental fluorosis or mottling of teeth in fluoridatedcommunities. However, in a letter to Irish Medical Journal, Professor O’Mullane changedthis 50% figure. He now states, referring to the 1997 study of dental fluorosis in 12year olds (Eastern Health Board), “. . . 20% had questionable/very mild fluorosis” and“. . . the remaining 4% showed evidence of mild/moderate fluorosis”.191 Therefore, 24%of this study had dental fluorosis. Moreover, the study which Professor O’Mullanerefers to in his letter, is also at the age limit for accurate assessment for dental fluorosis.“. . . Examination of age groups under 12 years of age (with few permanent teeth) in areaswhere fluoride content is relatively low introduces an error of considerable magnitude”.192
In essence, if not all teeth have erupted into the mouth an accurate assessment of dentalfluorosis is impossible.
58
DRAFT
7.8 Dental Fluorosis Levels according to the York Review
The York Review, “. . . an important document which looks at the general side effectsof water fluoridation”193, agrees closely with Professor 0’Mullane’s earlier 50% estimate.They concluded that 48% of a fluoridated population would develop dental fluorosis.“Fluorosis was the most widely and frequently studied of all the possible adverse effectsconsidered”194 “The prevalence of fluorosis at a water fluoride level of 1.0ppm was es-timated to be 48% for any fluorosis and 12.5% for fluorosis of aesthetic concern”.195 Ineffect, after assessing 88 studies, they concluded 48% of a fluoridated population willshow some signs of fluoride tooth damage. One eighth of a fluoridated population willhave tooth damage, which may require dental intervention. Proponents of fluoridationin Ireland find that this is an acceptable pay-off. Professor O’Mullane declares that,“at present it would seem that these do not pose an aesthetic problem and, in my viewshould be weighed . . . against dental decay. In other words there is a risk benefit deci-sion to be taken between dental caries and dental fluorosis”.196 Interestingly, Dr. HardyLimeback, Head of Preventive Dentistry, University of Toronto and past president ofCanadian Association of Dental Research, has an alternative viewpoint. He states that,“I treat patients with fluorosis all the time in my dental surgery and there is a growingnumber of patients who are terribly unhappy with their teeth affected with fluorosis. Influoridated areas throughout the world the incidence of very mild fluorosis . . . is as highas 80%”.197
7.9 Risks
There is a growing concern that nearly half of the population has some form of dental flu-orosis. Though contending the York figures, Dr. Gavin agrees that, “. . . dental fluorosislevels need to be monitored and action taken to reduce them if necessary”.198 To reducedental fluorosis in a population it is first necessary to identify the risks. As highlightedearlier, since the introduction of fluoridation in Ireland, there is an increase in total fluo-ride intake. Total fluoride intake has increased through a variety of sources. For example,any use of fluorides, whether systemic or topical, in caries prevention and treatment inchildren results in ingestion and absorption of fluoride into the blood circulation.199 Den-tal fluorosis is a dose response condition.200 This means that the more fluoride absorbedby the body the greater the risk and severity of the condition. Therefore, “it is the totaldietary intake of fluoride from all sources that is critical in the development of dentalfluorosis”.201 Given this, it is crucial to consider the total fluoride intake.
7.10 Total Fluoride Intake
To date, in Ireland, there is no effective measure of either fluoride intake in the pop-ulation or the individual. The Department of Health hold the empirical belief thatone systemic source (water fluoridation) and one topical source of fluoride (fluoridatedtoothpaste) provide “adequate levels of fluoride“. But figures from the United Statesquestion this hypothesis. By 1991, the average fluoride intake in fluoridated Americawas approximately 6.5mg.202 This is many times the 1960s estimate for fluoride intake in
59
DRAFT
“optimally fluoridated” areas. In 1996, the Department of Health in the U.K. publishedsafe fluoride intakes at various ages: in adults, this is 3mg per day. This is equivalentto drinking 3 litres of water in Ireland but does not consider other sources of fluoride.However, there are many additional sources of fluoride. These include dental productscontaining fluoride such as fluoride toothpaste, fluoride supplements and fluoride dentalgels and mouth rinses, and are discussed in a subsequent section. There are also manydietary sources of fluoride.
1. Tea.
It is known that fluoride accumulates in the leaves of the tea plant. Ireland hasthe highest per capita consumption of tea in the world. In 1998, the Journal ofthe Irish Dental Association published a review of high levels of fluoride in teaand their dental significance in Ireland.203 Two studies from the U.K. reported onupper levels of fluoride intake from tea only. These ranged from 2.7mg204 to 9.9mg.205 These high levels of fluoride intake have serious bone implications and arediscussed in the skeletal fluorosis section. The Irish review concluded that, “. . . it isrecommended that a research project be carried out to analyse the fluoride levelsand the rates of the releases from teas available on the Irish market”.206 Therehave been no such studies. Kiritsy, et al., in an assessment of fluoride levels in teacalled for manufacturers of tea to label the fluoride content of their products.207
Another study (Pang et al.) concluded that the fluoride content of tea, preparedwith de-ionised water (unfluoridated) and drunk by children, “must be consideredas a risk for causing aesthetically significant dental fluorosis”.208
2. Fruit Juice.
There have been several studies into the levels of fluoride in fruit juices.209 Theyconcluded that intake of fluoride from juices or juice flavoured drinks is a factorin the development of dental fluorosis. In 1999, another study of fizzy drinks hadsimilar results.210 Grape juice in particular is high in fluoride.211
3. Fish.
Some fish contain high levels of fluoride. Canned sardines contain 61mg/kg212 andshrimp are very high in fluoride at 61.73mg/kg.213 Other canned fish and shellfishare also noticeably high in fluoride.214
4. Processed Foods.
Any foods manufactured in a fluoridated area using fluoridated water will containelevated levels of fluoride. Cereals for infants for example contained 3–4 timesmore fluoride when manufactured in a fluoridated area.215 Soft drinks and beerproduced in Ireland are more likely to have a raised fluoride level. Guinness usetreated reservoir water in production. This water is fluoridated.
5. Other sources.
60
DRAFT
Other sources include pesticides (e.g. cryolite), pollution216 (e.g. unleaded petrol,coal burning, brick making), cigarette smoke, pharmaceuticals and anaesthetics(e.g. prozac and rohypnol), and aerosol (e.g. chlorofluorocarbons).
7.11 Risk from Systemic Fluorides.
In addition to the sources listed above, public water fluoridation is an important sys-temic source of fluoride in Ireland. “Currently, over 70% of the Irish population havefluoridated water supplies”.217 There are members of these communities, which are moresensitive to fluoride ingestion. The Royal College of Surgeons of Ireland says, “. . . windowof maximum sensitivity occurs during the first year of life. . . ”.218 During the first yearof life, exposure to fluoride occurs mainly during bottlefeeding.219 In Ireland, there isconcern that in fluoridated areas when formula feed is made up using tap water, infantsare receiving an overdose of fluoride.220 Due to an infant’s size it has been estimatedthat a newborn will receive, three times the safe fluoride limit set by the British Medi-cal Association. A three-month old, due to greater intake, will receive nearly six timesthis limit.221 An Australian study confirms this. “Prolonged consumption (beyond 12months of age) of infant formula reconstituted with optimally fluoridated water couldresult in excessive amounts of fluoride being ingested during the enamel development ofthe anterior permanent teeth and therefore may be a risk factor for fluorosis of theseteeth”.222 Dr. Limeback also concurs, “we carried out a study, published last year, wherewe determined that children who are breast-fed until age one, are at less risk of devel-oping dental fluorosis because when you use city (fluoridated) tap water to make up theformula you increase the fluorosis incidence”.223 W.H.O. recommends that, “. . . stepsshould be taken to reduce fluoride ingestion during the ages of tooth development”.224
Yet, there is still no advice from the Department of Health regarding fluoride intakeand bottle-feeding infants. Dr. Limeback suggests an effective method of reducing den-tal fluorosis in Ireland. He postulates, “if the fluoridation equipment was shut downtomorrow in Ireland, at most one would see one extra filling for every fourth person.If one continues to fluoridate, every sixth person will suffer from fluorosis of the kindmild/moderate. . . with about ten surfaces affected”.225 Even proponents of fluorides arenow questioning the efficacy of fluoridation due to the increase in dental fluorosis as thebenefit from fluoride is topical, not systemic. Fejerskov, et al., agree,
“since the predominant cariostatic effect of fluoride is not due to its uptakeby the enamel during tooth development, it is possible to obtain extensivecaries reductions without a concomitant risk of dental fluorosis”.226
7.12 Risk from Fluoride Supplements
In non-fluoridated areas, children are encouraged to take fluoride supplements. However,in recent years, recommendations have been reduced. The reason is the implication ofsupplemental fluoride in the development of dental fluorosis. “Fluoride supplements area risk factor for dental fluorosis, though their contribution to the increase in fluorosisprevalence is less than that of water fluoridation and fluoridated dentrifices because of
61
DRAFT
their more limited and shorter use”.227 There is increasing pressure to stop this sup-plementation. “It is important for dental practitioners to determine the fluoride intakeof every patient before recommending or dispensing any fluoride supplementation”.228
A study looking at the effectiveness of sodium fluoride drops found that, “considerabledental fluorosis was found in both regular and irregular user groups of the fluoride sup-plement between 38–63% of children seen”.229 In 1994, Dr. Brian Burt, presented atthe Dietary Fluoride Supplement Conference of the American Dental Association. Heargued that, “the risks of using fluoride supplements in young children outweigh thebenefits”230 Similarly, due to the near epidemic levels of dental fluorosis in Canada, theCanadian Dental Association (from March 2000) now advises no fluoride supplementsfor children under seven years old.231 Dental fluorosis is also on the increase in non-fluoridated communities, with commercially prepared soft drinks, juices and processedfoods manufactured in fluoridated areas.232 In addition, the advent of fluoridated tooth-paste in the 1970s provides another fluoride source, and risk factor in the developmentof dental fluorosis.233
7.13 Risk from Topical Fluorides
Dr. Gavin claims that, “most fluorosis in this country is caused by young children swal-lowing too much toothpaste”.234 He continues, “it is a recommendation of the Depart-ment of Health that mothers and parents of young children must supervise the brushingof teeth of children under six years of age for a variety of reasons”.235 Current recom-mendations, from the Department of Health, state that, children should use no morethan a pea-sized amount of fluoride toothpaste. (However, there are many television ad-vertisements in Ireland showing large amounts of toothpaste on toothbrushes).236 TheUnited States has gone further and placed a poison warning on every tube of fluoridetoothpaste, which states, “Keep out of reach of children under six years of age. If youswallow more than used for brushing then seek professional advice or contact a poisoncontrol centre immediately”.237 U.S. Food and Drug Administration require this poisonwarning by law since 1997. Dr. Gavin recently expressed his opinion on this practice,“well I think putting a poison warning on it is carrying it a bit far, but I do think thatmanufacturers and suppliers of toothpaste should give much clearer advice in relationto the amount of fluoride toothpaste that should be used by young children”.238 It isclear that authorities and studies alike also mirror this advice of prudent use of fluoridetoothpaste for young children.239 240
7.14 Implications of Dental Fluorosis
Proponents of fluoridation refer to dental fluorosis as a “cosmetic effect”241, barely vis-ible to the sufferer and therefore ’of little concern’. Professor O’Mullane agrees, “mostchildren who have these white lines are not aware they have them”.242 However, a studyinto the perceptions of dental fluorosis found that “. . . the appearance would increas-ingly embarrass the child as the TF score (level of fluorosis) increased. Observers,except the dentists, tended to feel that higher TF scores indicated neglect on the part
62
DRAFT
of the child”.243 Returning to the York Review, dental fluorosis of aesthetic concern,will likely affect 12.5% of a fluoridated population.244 This term aesthetic concern referspurely to the perception of this tooth damage and projects that these patients will, in allprobability, request treatment to cover this irreversible tooth damage. There are severaltreatment options available to remove or cover this tooth damage. Dr. Limeback, inhis presentation to the Dail committee, highlights some of these options, “many dentistsuse fillings such as cosmetic bonding or porcelain veneers. A conservative approach,one which I use, is a simple micro-abrasion procedure to remove the surface defectiveenamel”.245 Dr. Don Mac Auley of IDOF agrees that, “these teeth are usually brittleand more susceptible to wear. Expensive cosmetic dental treatment is usually the onlytreatment and is not available under the PRSI or medical card schemes”.246 Interestingly,the American Dental Association reported that dentists’ profits in fluoridated areas are17% greater than those working in unfluoridated areas.247 The Department of Health ac-cepts that dental fluorosis “. . . was always known and was accepted as a trade-off againstthe dental benefits”.248 However, concerns have been expressed both in Ireland and inother countries about possible adverse health effects from water fluoridation.249 Thereis increasing concern that dental fluorosis is a sign of more serious health damage. Dr.Limeback concludes, “where there is smoke, there is fire. Fluorosis is the first sign ofharm. Soon, we will see people with obvious, measurable systemic illness”.250 Alreadya Polish study in 1993 found that children with dental fluorosis had identifiable bonechange.251 “Their findings indicate greater trabecular [bone] height and area in childrenwith dental fluorosis than in controls”.
7.15 Fluoride and Bone
The fluoride ion has an attraction for calcifying tissues. In fact as Dr. Gavin states,“fluorosis levels are a bio-marker for the level of fluoride in the body”.252 And fur-ther, “dental fluorosis is past evidence of damaging levels of fluoride in the body.” TheW.H.O. agrees, “it is widely recognised that we retain about 50% of the fluoride that weingest, with it being incorporated into our teeth and bones”.253 “Fluoride is also a toxicsubstance”254 Despite the widespread use of this “toxic substance”, the York Reviewexpressed surprise at the poor quality research surrounding the issue of public waterfluoridation. They concluded that, “given the level of interest surrounding the issue ofpublic water fluoridation, it is surprising to find that little quality research has beenundertaken”.255 Not surprisingly, the storing of a toxic substance in parts of the body,over a lifetime, along with the lack of its demonstrated safety, gives raise for concern. Dr.Limeback explains, “the York Review stated that no-one has designed a careful studyto measure the safety of fluoride. We do not know what the long-term effects mightbe. We conducted a study comparing Montreal residents (unfluoridated) and Torontoresidents (fluoridated). The hip bones of Toronto residents have twice the amount offluoride in them and, at such levels, some are at risk of breaking their bones. The wa-ter in Toronto has been fluoridated for approximately 30 years”.256 Professor 0’Mullanecounters this evidence, “[fluoridation] does not pose a hazard to health or any specificaspect of health”.257 According to the W.H.O., “many epidemiological studies of pos-
63
DRAFT
sible adverse effects of the long term ingestion of fluoride via drinking water have beencarried out. These studies clearly establish that fluoride primarily produces effects onskeletal tissues (bone and teeth). Low concentrations provide protection against dentalcaries, especially in children”.258 This concern for calcified and skeletal tissues, in partic-ular bone, resulted in many investigations into the relationship between fluoridation andfractures of bones. The majority of these scientific studies focus specifically on hip frac-ture. The York Review recently concluded that, “. . . there is no clear association of hipfracture with water fluoridation. The evidence on other fractures is similar”.259 However,in such a review “. . . limitations are inevitable”.260 For example the York Review didnot include animal or laboratory studies. In addition, they also excluded fluoride intakefrom other sources (see “Total Fluoride Intake”). These other sources are essential, tofully assess the impact of fluoride on health, as “. . . total fluoride exposure has increasedover recent years, partly in industrialised nations”.261 The York Review acknowledgedthis, “. . . it would seem sensible that any future studies should attempt to measure totalfluoride intake in areas being researched.262
George Glasser, an investigative journalist and medical writer, summarised this error,in his presentation to the Dail Committee on Health and Children, “it is fundamentallyflawed. One cannot look at something without looking at the whole picture.“263 He alsopointed out that the York Review completely ignored skin absorption of fluoride frombathing in fluoridated water. Mr. Glasser explained, “in actuality, one absorbs morecontaminants through one’s skin and bathing than in drinking water. The fluoridationpeople cannot produce one study on dermal [skin] absorption. That means they aresaying the dose they put in the water is based on ingestion only. The York Reviewbased their studies on ingestion only”. Nevertheless, the Irish Department of Healthcontinues to reassure: “concerns about adverse health effects other than dental fluorosishave not been substantiated”.264 But, there has never been a health study carried outin Ireland in forty years of fluoridation so the local health effects of water fluoridation,specifically in Ireland, remains unknown. The former Minister of Health, Micheal Martin,recently declared that such health surveys, relating to hip fractures, were impractical.The reason; Ireland’s population is too small.265 Opponents of fluoridation find thisattitude unacceptable and see the lack of policy as a breach of the law placed to protectpublic health.266 Others have voiced their concerns, “successive health ministers havefailed to monitor public health”.267 Dr. Maire O Connor, Faculty of Public Healthexplains, “with a population of 3 million and only just over 2 million are on public pipedwater supplies, it would be a long time before we’d would expect to show up anythingin this size. I think we have to continue monitoring the US, Canada, Australia, NewZealand, the 10 percent in the UK who are on it to try and pick up anything therebecause just the size of the population alone, we would not expect necessarily to findsomething”.268
7.16 Hip fracture
There have been many studies investigating the relationship between water fluoridationand hip fracture and other bone fractures. In 1993, the Agency for Toxic Substances
64
DRAFT
and Disease Registry (ATSDR) in the United States highlighted their concerns of thepublished studies on hip fractures. They commented, “the weight of evidence from theseexperiments suggests that fluoride added to water can increase the risk of hip fracturesin both elderly women and men. . . If this effect is confirmed, it would mean that hipfracture in the elderly replaces dental fluorosis in children as the most sensitive endpointof fluoride exposure”.269 In the last ten years there have been around 18 studies looking atthe effect of water fluoridation on hip fracture alone. Of these 18, 10 show an associationbetween fluoride exposure and increased hip fracture, however 8 do not.270 Although,the York Review found, “overall the findings of studies of bone fracture effects showedsmall variations around the ’no effect’ mark”, there are still studies in the literatureshowing a link between fluoridation and hip fracture.
Professor O’Mullane, in his reply to questions at the Dail Committee, stated thatthere was no link between hip fracture and fluoridation. He asserted there was conclusiveevidence.271 Professor O’Mullane cited two studies one from the UK by Drs. Hilliers andCooper and another study from Australia. The UK study concluded that, “. . . there is alow risk of hip fracture for people ingesting fluoride drinking water at concentrations ofabout 1ppm. This low risk should not be a reason for withholding fluoridation of watersupplies”.272 The other study from Australia, not included in the York Review, concludes“water fluoridation appears. . . to have little effect on fracture risk, either protective ordeleterious, at a population level.273 In addition, it suggests that further investigation isrequired on an individual level.
Dr. Limeback agrees, “that these studies miss the individual response to fluoride.There are people who have kidney failure, who are accumulating so much fluoride intheir system that their skeletal system is riddled with fluoride. There is no way that onecan tease out those numbers from these studies. A clear, well controlled study obviouslymust be done”.274
Another study, included in the York Review, offers conflicting evidence to ProfessorO’Mullane’s submissions. “We found a small but significant increase in the risk of hipfracture in both men and women exposed to artificial fluoridation at 1 ppm, suggestingthat low levels of fluoride may increase the risk of hip fracture in the elderly”.275 Anotherstudy, one of the largest studies ever carried out on hip fracture, Jacobsen and co-workers examined the possible association of hip fracture with water fluoridation inthe US for white women and men over 65. After exclusions, they examined 218,951patients. They concluded, “There was a small statistically significant positive associationbetween fracture rates and fluoridation”.276 (As discussed earlier the York Review didnot include animal studies but there is evidence in the literature that when rats aretreated with fluoride their bones become more brittle).277 278 The Faculty of PublicHealth in Ireland declares that other studies279, showing a link with hip fracture, usedindividual measurements of bone mass. “Although exposure to fluoride in drinking waterwas associated with reduced radial bone mass, this did not occur until the levels were3.5–4.0 mg/litre, far in excess of that recommended for optimal fluoridation”.280
65
DRAFT
7.17 Skeletal fluorosis
Skeletal fluorosis affects millions of people worldwide especially in India, Pakistan, Chinaand parts of Africa. High levels of naturally occurring fluoride in the soil and subse-quently in well water cause this condition. In relation to skeletal fluorosis, the W.H.O.declared, “there is no evidence to suggest the guideline value of 1.5mg/litre set in 1984needs to be revised. Concentrations above this value carry an increasing risk of den-tal fluorosis, and much higher concentrations lead to skeletal fluorosis”.281 Again, itis important when considering skeletal fluorosis that the overall fluoride intake is es-timated. Not just fluoride from water but from other sources, as described earlier in“Total Fluoride Intake”. The clinical symptoms of this chronic fluoride poisoning hasthe following stages282: - -Pre-clinical phase: asymptomatic; slight radiographically-detectable increase in bone mass. - -Phase I: Musculoskeletal: sporadic pain; stiffnessin joints; osteosclerosis of pelvis and spine. - -Phase II: Degenerative and destruc-tive: chronic joint pain; arthritic symptoms, slight calcification of ligaments; increaseosteosclerosis/cancellous bones; with or without osteoporosis of long bones. - -Phase
III: Crippling fluorosis: limitation of joint movement; calcification of ligaments/neck,spinal column; crippling deformities/spine and major joints; muscle wasting; neurologicaldefects/compression of spinal cord.
Fluoride levels of 10-20mg per day for 10-20 years will cause Phase III-CripplingFluorosis.283 If we extrapolate this figure to include a normal lifetime then you are atrisk from skeletal fluorosis if you ingest 2.5–5.0 mg for 40–80 years. By 1991, the averagefluoride intake in fluoridated America was approximately 6.5mg.284 It is possible thatfluoride intake in Ireland is also within this range. In 1996, the Department of Healthin the U.K. published safe fluoride intakes at various ages: in adults, this is 3mg perday. This is equivalent to drinking 3 litres of water in a fluoridated area not includingfluoride from any other source.285
Ireland does not have any figures for safe fluoride intake nor research, to date, of levelsof fluoride intake of the Irish public. The focus in Ireland is more on dental concerns, forexample, “in developing countries where fluoride levels are naturally high, research onbone is the main topic of interest. In countries with established fluoridation programmeslike Ireland dental epidemiology is the main focus of research”.286
Department of Health and Children acknowledge that “. . . in countries with unusu-ally high levels of fluoride at ten parts per million or higher in drinking water, skeletalfluorosis is a significant public health problem”.287 But, in an article published in TheGuardian, called “Nutrition is the key to healthy bones and teeth“ on 16/7/1998, ref-erence is made to a village near Delhi, India with water fluoride levels between only0.6 and 1.6ppm and 17% of the population suffers with skeletal fluorosis. The W.H.O.agrees, “crippling skeletal fluorosis develops where drinking water contains over 10 mgof fluoride per litre”.288 However, as shown in the box above, there are three phasesof skeletal fluorosis before the onset of crippling skeletal fluorosis. The question arisescould our total fluoride intake be reaching dangerous levels. Therefore, some individualsmay already be experiencing early stages of skeletal fluorosis because “. . . early cases[of skeletal fluorosis] may be misdiagnosed as rheumatoid or osteo arthritis”.289 Signif-
66
DRAFT
icantly, the W.H.O. verifies that, “skeletal fluorosis (with adverse changes in bone) isobserved when drinking water contains 3- 6mg/litre of fluoride per litre”.290 Dr. HardyLimeback responds affirmatively, “there is clear association of fluoride accumulation inthe various stages of skeletal fluorosis and hip and bone fractures, including forearmfractures, vertebral fractures etc. That has been well documented in the endemic fluo-rosis areas of China, India and Africa. We are at a stage in North America where we arestarting to accumulate so much fluoride in our systems that we are close to stage one ofskeletal fluorosis. If we allow fluorosis to continue over a lifetime, we will see an increasein fractures”.291
7.18 Cancer
The Royal College of Physicians of Ireland explain that, “claims have been made thatfluoride results in an increased occurrence of malignancies. The Knox report in Englandin 1985 failed to find such a link. In a review by Kaminsky et al in 1990 of the benefitsand risks of fluoride exposure, the conclusion was that “there is no evidence that chronicexposure to concentrations of fluoride reported to be greater than 2 mg/l in drinkingwater increase human cancer mortality or incidence”.292 In addition, the York Reviewconcludes, “there is no clear picture of association between water fluoridation and overallcancer incidence and mortality”.293
This is not conclusive as the York Review excluded all animal studies. The valuein animal laboratory studies is that they establish precise controls, but care is neededin extrapolating these results to humans. Therefore, a combination of laboratory andepidemiological studies (man in his actual environment) is optimal in establishing acausal link. These two factors coincided in a famous court case, of Paul Whitehead vBorough of West View (No Gd-4585-78 on the docket of the Allegheny County Court ofCommon Pleas in Pittsburgh, U.S. Judge John Flaherty heard the case). This Americancase revolved around whether fluoridation posed a threat to health. There were manypresentations including both laboratory and epidemiological studies.
One of the more important laboratory studies followed the work of Dr. Alfred Tay-lor, a biochemist at University of Texas, who found that cancer prone mice drinkingwater containing fluoride at 1ppm and 10ppm, introduced as NaF (sodium fluoride),had shorter life spans by 9-10%.294 This relationship was statistically significant com-pared to the control mice, drinking distilled water. Drs. Taylor and Taylor followed thiswith another study, which showed that fluoride in water induced growth in implantedtumours.295
Dr. Dean Burk, Chief Emeritus of the U.S. National Cancer Institute, and Dr. Yi-amouyiannis, also presented a keynote study - comparison between the ten largest fluo-ridated cities and the ten largest non-fluoridated cities. Their extensive research showedthat, while cancer rates had been identical initially, after 20 years the fluoridated citieshad 10 percent more cancer deaths than the non-fluoridated ones.296
Based on these and other investigations both for and against public water fluoridationJudge Flaherty gave his findings on November 16, 1978. He understood, “. . . the solequestion before the court is whether fluoride may be a carcinogen”. He then found,
67
DRAFT
“. . . point by point, every criticism made of the Burk-Yiamouyiannis study was met andexplained by the plaintiffs. Often the point was turned around against the defendants. Inshort, this court was compellingly convinced of the evidence in favour of the plaintiffs”.In effect, fluoride is a carcinogen. Jurisdiction to enter this decree was sustained onappeal, but on a technicality of administrative law, it was found there was no jurisdictionin the court in the first instance. The findings of Judge Flaherty remain undisturbed.
Following this case, a special committee of the Environment Ministry in Quebec,Canada returned a report on the findings of this court. This report, published in 1979,recommended executive suspension of fluoridation in Quebec.297 This was accepted andstill exists today.
In contrast to Judge Flaherty’s findings, the International Agency for Research onCancer concluded, in relation to carcinogenicity, that the limited data provided inad-equate evidence of carcinogenicity in experimental animals. This in itself is quite sur-prising considering the results from the National Toxicology Program animal study. In1977 U.S. Congress ordered the United States Public Health Service, to carry out ananimal study to review the relationship between fluoride and cancer. The initiative forthis important animal study followed the furore caused by the cancer rates study byBurk and Yiamouyiannis listed above. The NTP study published in 1990, they found adose-related increase in osteosarcoma (bone cancer) in male rats.298
They also found other cancers but these were eliminated by a peer review processwhich so angered Dr. William Marcus, who was then head of toxicology of the waterdivision of the US Environmental Protection Agency, that he exchanged several memoswith his superiors. Finally, the report concluded that fluoride is an equivocal (probable)carcinogen. However, the authors continued to stress that the levels of fluoride were veryhigh but Dr. Marcus has pointed out the fluoride levels in the rats’ bones was within therange you expect in the human population. The U.S. Department of Health and HumanServices (1991) point out that a study commissioned by Procter and Gamble, the makersof Crest toothpaste, failed to reproduce the same result in their rat studies.299 Finally,the W.H.O. admit that there “was equivocal evidence of carcinogenicity in one study inmale rats, extensive epidemiological studies have shown no evidence of it humans”.300
7.19 Bone Cancer
There was much scepticism about how this relationship, between fluoride and bonecancer in rats, affected the human population. After all, these were animal studiesalone.
Under the SEER (Surveillance, Epidemiology and End Results Program Cancer Reg-istry) 16 years of cancer incidence data was examined for the years between 1973 and1987, covering approximately 10% of the United States population. This examinationturned up higher rates of osteosarcoma (bone cancer) in young males in fluoridated areascompared with non-fluoridated areas. However, the US Department of Health and Hu-man Services (1991) explained this result as follows; “the amount of increase observedin young males was greater in fluoridated than in non-fluoridated areas. Although thereason for the increase in young males remains to be clarified, an extensive analysis
68
DRAFT
reveals that it is unrelated to the introduction and duration of fluoridation”.301
Osteosarcoma is a rare cancer of bone, but is one of the most prevalent cancers inyoung males aged 9-20. It appears to strike young men in the period of rapid bonegrowth during puberty. Historically there is a link between this disorder and the ini-tial fluoridation trials in Kingston and Newburgh, in the United States302 A NationalAcademy of Sciences report in 1977 commented on this fact, “there was an observationin the Kingston-Newburgh study303 that was considered spurious and has never beenfollowed up. There was a 13.5% incidence of cortical defects in bone in the fluoridatedcommunity but only 7.5% in the non-fluoridated community. . . Caffey (1955) noted thatthe age, sex, and anatomical distribution of these bone defects are ‘strikingly’ similar tothat of osteogenic sarcoma. While progression of cortical defects to malignancies has notbeen observed clinically, it would be important to have direct evidence that osteogenicsarcoma rates in males under 30 have not increased with fluoridation”.
The Royal College of Physicians of Ireland highlights an investigation offering con-flicting evidence.304 “A study was carried out in New York by Mahoney et al in 1991 toinvestigate the potential relationship between water fluoridation and bone cancer. Theresulting data did not support an association between fluoride in drinking water and theoccurrence of cancer of the bone”.305 The following year another study, published by theNew Jersey Department of Health offered conflicting evidence. Dr. Perry Cohn issued areport entitled: “An Epidemiologic Report on Drinking Water and Fluoridation”. Thisreport indicated that in three counties of New Jersey there was approximately 7 timesthe osteosarcoma rate in young males in the fluoridated communities compared to thenon-fluoridated communities. For the years (1979-87) in the fluoridated communities (inMercer, Middlesex and Monmouth Counties) there were 22 cases per million and in thenon- fluoridated communities there were 3.2 cases per million.306 It must be added, thata further investigation in 1995 failed to show a similar correlation.307
7.20 Uterine Cancer
The Japanese Okinawa Islands were under United States administration from 1945–1972.During this period, fluoridation schemes were installed in most regions. Dr. E. Tohyama,Department of Preventive Medicine, University of Ryukyus, Okinawa, studied the re-lationship between fluoride levels in drinking water and uterine cancer death rates.308
He concluded that there was a significant positive correlation between fluoride levels ondrinking water and uterine cancer deaths. In addition, he found this relationship re-mained significant after considering possible confounding factors. Finally, he discoveredthat the time trends in these cancer deaths were related to changes in water fluoridationpractices. The Royal College of Physicians of Ireland disputes the methodology used inthis study and reassures that “this association has not been found elsewhere”.309
7.21 Fluoride and the Brain
In 1982, studies in China provided the initial evidence that fluoride could affect thebrain.310 311 Up until then, it was accepted that fluoride was unable to cross the
69
DRAFT
blood/brain barrier. Dr. Phyllis Mullenix and colleagues published a landmark study in1995.312 Dr. Mullenix specialises in neurotoxicity (i.e. the study of toxic effects on thenervous system). From 1982-1986, Dr. Mullenix worked at the Forsyth Dental Infirmaryfor Children in Boston developing a very accurate animal model, which could measurebehaviour. The completed computer program was noted for this achievement in theWall Street Journal. Mullenix and her colleagues set about investigating the effects ofdifferent fluoride concentrations on the rat’s behaviour, using the computer model. Shealso measured the levels of fluoride in their blood and brains. She surprisingly concludedthat fluoride accumulated in brain tissue. In addition, there were behavioural changes,which depended on both the level of fluoride exposure and the age of exposure. Mullenixfound that males were most sensitive to prenatal exposure and females to weanling andadult exposures. This altered behaviour, “flagged potential for motor dysfunction, IQdeficits and/or learning difficulties”.
In a non peer-reviewed critique by Gary Whitford, circulated by the Centres for Dis-ease Control, Division of Oral Health, the levels of fluoride used were criticised (i.e. theywere very high). However, Dr. Mullenix reassures that the fluoride levels used were lessthan one tenth the amount found in children’s plasma one hour after receiving topicalfluoride applications of dental fluoride gels, or equivalent to humans drinking 5-10 ppmfluoridated water. Dr. Mullenix stated, “thus humans are being exposed to levels offluoride we know alters behaviour in rats”. Following this landmark study, a letter to“Neurotoxicology and Teratology” questioned its validity. The authors declared, “we donot believe the study by Mullenix et al. can be interpreted in any way as indicating thepotential for NaF (sodium fluoride) to be a neurotoxicant”.313
7.22 Alzheimer’s Disease
The Mullenix study was not included in the recent York Review. However, they didinclude a study which “found a statistically significant negative effect (increased risk)of water fluoride on Alzheimer’s disease”.314 In conclusion, on this and other studies,the York Review pointed to the lack of control for other compounding factors. Theyfinally projected, “overall, the studies examining other possible negative effects provideinsufficient evidence on any particular outcome to reach conclusion”.315
There are animal studies, excluded from York, which demonstrate that when rats arefed aluminium fluoride they develop loss of smell, short term memory loss and othersimilar characteristics of Alzheimers.316 Dr J. A. Varner et al, concluded, “the presenceof low levels of fluoride in the drinking water, equal to the amount found in fluoridatedwater, caused damage to the tissues of the brain similar to Alzheimer’s and other formsof dementia, as well as kidney damage”317. Following this landmark study, a reportfrom the American Dental Association questioned the experimental design involved.318
Another study found there were fewer cases of degenerative dementia in fluoridatedareas319 but “no measure of statistical significance of this effect was provided”.320
There are recent studies from China, which indicate a lowering of IQ of children, as afunction of their exposure to fluoride.321 322 However, the York Review reviewed of thesestudies and concluded, “skeletal fluorosis and IQ were both negative (increased risk) in
70
DRAFT
association with water fluoride, but again no measure of the statistical significance ofthis association was presented”.323
7.23 Silico-fluorides and Lead levels in Children’s blood
In individual studies, hyperactivity in children and criminal behaviour is linked to in-creased blood lead levels. Lead is notable for its effects on the brain. A most recentstudy from Dartmouth College in the United States investigated the blood lead lev-els of 151,225 children aged 0-6 inclusive, living in 105 communities of populations from15,000 to 75,000.324 They compared these lead levels with the type of fluoridation schemeemployed. They concluded, “for every age/race group, there was a consistently signif-icant association of Silico-fluoride treated community water and elevated blood lead”.In essence, their investigations concluded that children living in fluoridated areas, us-ing silico-fluorides as the fluoridating agent, had higher levels of lead in their blood.Silico-fluoride is the fluoridating agent used in Ireland. Miles and Coplan also com-ment, “chronic, low-level dosage of silicofluoride (SiF) has never been adequately testedfor health effects in humans”. In Ireland, the Irish Medicines Board, verified that thissilico-fluoride “. . . is not registered as a medicine, is unlicensed and has never been provensafe or effective”.325
Following the publication of Miles and Coplan’s study, a rebuttal paper, addressing thesilico-fluorides study, was published in the Indian International Journal of EnvironmentalStudies. This stated that, “. . . we conclude that no credible evidence exists to show thatwater fluoridation has any quantitatible effects on the solubility, bio-availability, bio-accumulation, or reactivity of lead(0) or lead(2) compounds”.326
7.24 The Pineal Gland
The pineal gland lies in the centre of the brain but is outside the blood/brain barrier.It has a high blood supply and is a calcifying tissue similar to teeth and bone. Thepineal gland is implicated in melatonin production. Dr. Jennifer Luke, investigated thelevels of fluoride in the crystals in the pineal gland.327 She found these levels on average9000ppm fluoride in the crystals and estimated 300ppm in the tissue itself This level isfar in excess of the 1ppm known to inhibit many enzymes.
Dr. Luke next examined the effect of dosing Mongolian gerbils (the animal of choicefor studying the pineal gland) with fluoride. She found that the melatonin productionwas reduced in the gerbils with raised fluoride exposure. Luke postulates that fluoride isinhibiting the enzyme catalysts crucial for production of serotonin or melatonin. Mela-tonin is very important in the regulation and timing of puberty. Of particular interest,is the fact that in the United States there is an earlier onset of puberty, especially ingirls, and no one knows what is causing this.328 Of historical interest is the Newburgh-Kingston study in 1955 (ten years after fluoridation was begun). When children wereexamined it was found that the girls in fluoridated Newburgh reached menstruation fivemonths earlier, on average, than the girls in non-fluoridated Kingston.329
71
DRAFT
7.25 Other Related Health Implications
7.25.1 Down’s syndrome
The York Review looked at six studies which investigated the association between Down’sSyndrome and fluoridation. Three of the studies show an increased risk of Down’sSyndrome,330 331 332 one found a reduced association333 and one found no association.334
The remaining study produced a mixed response.335 “None of the three studies thatfound a negative association (increased risk) presented any measure of statistical signif-icance”. The York Review found the evidence inconclusive.
7.25.2 Renal Disease
The Royal College of Physicians quotes Kaminsky et al336 in reassuring that exposureto fluoride in drinking water does not increase the risk of renal disease.337 However,they also acknowledge the conclusion of this study calls for “. . . studies in the effects offluoride in individuals with renal insufficiency are needed”.338
As discussed earlier, fluoride is a toxic substance. The W.H.O. state that, “it is incor-porated into teeth and bones; there is virtually no storage in soft tissues. Incorporationinto teeth and skeletal tissues is reversible: after cessation of exposure, mobilisation fromthese tissues takes place. Fluoride is excreted mainly via urine, feces and sweat”.339
“Approximately 50 percent of the daily intake of fluoride is cleared by the kidneys”.340
People unable to clear this “toxic substance” from their bodies will more likely sufferfluoride damage. Therefore, it follows that, “subsets of the population may be unusuallysusceptible to the toxic effects of fluoride and its compounds. These populations includethe elderly, people with deficiencies of calcium, magnesium and/or vitamin C, and peo-ple with cardiovascular and kidney problems”.341 There is genuine concern that peoplewho have kidney problems cannot clear fluoride from their systems. Therefore, the fluo-ride builds up and increases the risk of fluoride poisoning. “Because fluoride is excretedthrough the kidneys, people with renal insufficiency would have impaired renal clearancefor fluoride”.342 This is also particularly worrying for elderly people. Elderly people havereduced renal fluoride clearance after the age of 50. “This decreased clearance of fluoridemay indicate that elderly people are more susceptible to fluoride toxicity”.343
7.25.3 Allergic responses
The American Academy of Allergy reviewed clinical reports of possible allergic responsesto fluoride and concluded, “there is no evidence of allergy or intolerance to fluorides asused in the fluoridation of community water supplies”.344 However, there are those whocomplain of suffering a range of symptoms when exposed to fluoride or fluoridated water,and whose symptoms disappear when they remove the source of fluoride. Dr. Waldbottdocumented this illness after many years of investigation.345
Dr. Waldbott, an allergy specialist, described six cases of urticaria (rash) due tofluoridated water.346 In one case of a forty year old woman, the relation of the urticariato fluoride in water was substantiated by a double-blind test.347 The patient was required
72
DRAFT
to take a tablespoonful of water daily from three bottles labelled 1, 2 and 3, using eachfor a week at a time. One bottle contained 1 mg of fluoride per tablespoonful but neitherthe patient nor her attending physician knew which one it was. The urticaria reappearedon the third day of using the fluoride solution. Waldbott, also reported the case of a 62year old woman who developed the allergic symptoms of rhinitis (runny nose), allergicsinus disease and urticaria (rash) within hours of using fluoridated water with an intakeof 1 to 2 mg a day.348
In addition, eight physicians in Holland conducted double blind studies which con-firmed a similar phenomenon. 349 By double-blind testing (see above), with 60 patients,he showed that certain individuals were intolerant to fluoride and that exposure to thiscould reproduce gastrointestinal symptoms, stomatitis (sore mouth), joint pains, poly-dipsia (uncontrollable thirst), headaches and visual disturbances. Ulcers of the mouthhave been described in persons using fluoride toothpaste and in children who have hadtopical fluoride applications applied to their teeth.350 Douglas has described 133 casesof stomatitis from fluoride-containing toothpaste.351
Despite this evidence, the U.S. National Academy of Sciences reached a conflictingconclusion. They state, “the reservation in accepting (claims of allergic reaction) atface value is the lack of similar reports in much larger numbers of people who have beenexposed to considerably more fluoride than was involved in the original observations”.352
7.25.4 Infant Mortality
From the York Review, “three studies examined the association infant mortality andwater fluoride level. All three studies353 354 355 found a negative direction (increased riski.e. higher infant mortality in fluoridated areas) of association, but again no measure ofthe statistical significance of this association was presented and so it is difficult to drawconclusions form these results”.356
In Chile in the 1960s, Dr. Albert Schatz (best known for his discovery of the antibioticSteptomycin) investigated the relationship between artificial fluoridation and increaseddeath rates in Chile.357 He found that areas which received artificially fluoridated waterhad increased infant mortality. Fluoridation ceased in Chile in the 1970s. However,WHO figures verify that since 1985, fluoridation has started again. Now, 10% of Chileis fluoridated (approximately 1.5 million people). In 1993, in an affidavit, Schatz gaveevidence to the high levels of infant mortality after drinking water was fluoridated. Hestated, “in Chile, with widespread malnutrition and high infant mortality, it was notnecessary to observe a generation of people throughout their entire lifespan in order todetermine whether the effect of artificial fluoridation is or is not harmful. One could seethe lethal effect of fluoridation within the first year of life in terms of increased infantmortality”.
7.25.5 The Thyroid Gland
Further disputes and scientific controversy surround the effect of fluoride on the thyroidgland. Proponents of fluoridation, the American Dental Association, declare that, “there
73
DRAFT
are no available data to indicate that, in humans drinking optimally fluoridated water,the fluoride affects enzyme activities with toxic consequences”.358 However, there is abody of evidence contradicting this statement.
In the past fluoride was used as an anti-thyroid medication to treat hyperthyroidism(overactive thyroid). Fluoride can suppress the action of the thyroid gland. There is alsoa remarkable similarity between the symptoms listed for hypothyroidism (under-activethyroid gland) and those reported for fluoride poisoning. There is evidence that excessfluoride in water levels is a risk factor of more rapid development of thyroid pathology.359
Therefore, it appears that fluoride decreases the production of thyroid hormones. Hill-man et al., found that cattle afflicted with fluorosis developed hypothyroidism, anaemia,and eosinophilia of leukocytes360. Fluoride might be of some benefit for people sufferingfrom hyperthyroidism. But for a normal person, or perhaps someone who is sensitiveto fluoride, exposure to too much fluoride it could result in reducing thyroid hormoneproduction below normal and necessary levels (i.e. hypothyroidism).
It is not clear just how fluoride reduces thyroid hormone production. There is astudy demonstrating that changes in the pituitary-thyroid axis, in workers exposed tofluorides, were caused by disorders of the regulatory chain and fluorine impact on thyroidhormones’ metabolism at the level of target cells.361 In essence, this indicates a disruptionof enzyme activity. Additionally, there is evidence that fluoride competes with iodineuptake into the thyroid. There is an extensive study on mice receiving several fluoride-iodine combinations in addition to basal diet. They found that iodine and fluorine dohave mutually interacting effects on both goitre and fluorosis in the experimental mice.362
There is evidence that where fluoride intake is high and iodine levels are low there isan increase in the symptoms of iodine deficiency i.e. sub-clinical cretinism with mentalretardation.363
In contradiction to the above, it also appears that fluoride can also cause over-stimulation of thyroid tissue when the conditions are suitable. For example if thereis an iodine shortage then a condition called goitre may occur. In this condition thegland grows and grows producing a swelling in the neck. Because there are no thyroidhormones produced, there is nothing to switch off the stimulating signal (thyrotropin orthyroid stimulating hormone) which is produced by the pituitary gland as a responseto low thyroid hormone levels. Jooste et al have shown that high fluoride water levels,where iodine is sufficient, have been linked to goitre.364
7.25.6 Fertility
The York Review included a list of studies, which met criteria but were not included inthe main analysis. One study related to the association between fluoridation and birthrates.365 York concluded, in this study, that “. . . the way fluoride exposure is classifiedis unclear and misleading” However, Freni’s study concluded that “most regions showedan association of decreasing Total Fertility Rate (TFR) with increasing fluoride levels inwater”.366 He also suggested that more studies be carried out in relation to this effectin individual women. In other studies, there is further evidence of the adverse effectsof fluoride on human sperm367 and reduced testosterone in skeletal fluorosis patients.368
74
DRAFT
“Fluoride Fluoride toxicity may cause adverse effects in the reproductive system of malesliving in fluorosis endemic areas”. Animal studies have also reinforced this relationship.369 370
7.25.7 Mutagenicity
A mutagen is a substance that can induce genetic mutations. These are changes that canaffect structure, development and physical characteristics of resultant offspring. Manysubstances that are mutagens are also carcinogens i.e. cancer causing. The W.H.O.admits that “in mammalian cells, in vitro, fluoride causes genetic damage (includingchromosomal aberrations) at cytotoxic concentrations only (=10mg/litre), the mecha-nism is not known”. Scientists in many countries have demonstrated this is the case withfluoride.371 372 373 Fluoride is a well-known inhibitor of enzyme systems and this maywell be a viable explanation of its ability to cause genetic mutations.374 375 However,further reassurance from the W.H.O. reassures, “this genetic effect is probably of limitedrelevance for practical human exposure”.
7.26 US National Academy of Sciences
After three years work by eleven of the leading experts in their respective fields, theNational Academy of Sciences 500 page report ’Fluoride in drinking water a scientificreview of EPA’s standards (NRC3 2006) was published on 22nd March 2006. Below aresome of the key recommendations and conclusions:
1. Need for baseline data on fluoride exposure.
“Fluoride should be included in nationwide bio-monitoring surveysand nutritional studies; in particular, analysis of fluoride in blood andurine samples taken in these surveys would be valuable.” [1, p 9]
“To assist in estimating individual fluoride exposure from ingestion,manufacturers and producers should provide information on the fluoridecontent of commercial foods and beverages.” [1, p 71]
“The concentrations of fluoride in human bone as a function of expo-sure concentration, exposure duration, age, sex and health status shouldbe studied.” [1, p 9]
“Information is particularly needed on fluoride plasma and bone con-centrations in people with small-to-moderate changes in renal functionas well as in those with serious renal deficiency.” [1, p 9]
“More research is needed on the relation between fluoride exposureand dentin fluorosis and delayed tooth eruption patterns.” [1, p 9]
“To permit better characterisation of current exposures from airbornefluorides, ambient concentrations of airborne hydrogen fluoride and par-ticulates should be reported on national regional scales, especially for
3National Research Council (NRC) functions under the auspices of the National Academy of Sciences(NAS)
75
DRAFT
areas of known air pollution or known sources of airborne fluorides.Additional information on fluoride concentrations in soils in residen-tial and recreational areas near industrial fluoride sources also shouldbe obtained.” [1, p71-72]
2. Bone effects.
“A systematic study of clinical stage II and stage III skeletal fluorosisshould be conducted to clarify the relationship between fluoride inges-tion, fluoride concentration in bone, and clinical symptoms.” [1, p 10]
“More studies of communities with drinking water containing fluorideat 2 mg/L or more are needed to assess potential bone fracture risk atthese higher concentrations.” [1, p 10]
[NB this applies to all who consume high amounts of drinking waterwith 1mg/l of fluoride, since fluoride dosage depends on total waterintake].
3. Immuno-compromised subjects and cancer.
“Nevertheless, patients who live in either an artificially fluoridatedcommunity or a community where the drinking water naturally con-tains fluoride at 4 mg/L have all accumulated fluoride in their skeletalsystems and potentially have very high fluoride concentrations in theirbones. The bone marrow is where immune cells develop and that couldaffect humoral immunity and the production of antibodies to foreignchemicals.” p249
“There is no question that fluoride can affect the cells involved inproviding immune responses. The question is what proportion, if any,of the population consuming drinking water containing fluoride at 4.0mg/L on a regular basis will have their immune systems compromised?Not a single epidemiologic study has investigated whether fluoride in thedrinking water at 4 mg/L is associated with changes in immune function.Nor has any study examined whether a person with an immunodeficiencydisease can tolerate fluoride ingestion from drinking water.” [1, p 250]
“bone concentrates fluoride and the blood-borne progenitors could beexposed to exceptionally high fluoride concentrations. Thus, more re-search needs to be carried out before one can state that drinking watercontaining fluoride at 4 mg/L has no effect on the immune system.” [1,p 250]
“it is important to consider sub-populations that accumulate largeconcentrations of fluoride in their bones (e.g., renal patients). Whenbone turnover occurs, the potential exists for immune system cells andstem cells to be exposed to concentrations of fluoride in the interstitialfluids of bone that are higher than would be found in serum. From animmunologic standpoint, individuals who are immunocompromised (e.g.,
76
DRAFT
AIDS, transplant, and bone-marrow-replacement patients) could be atgreater risk of the immunologic effects of fluoride.” [1, p 258]
“In addition, studies could be conducted to determine what percentageof immunocompromised subjects have adverse reactions when exposedto fluoride in the range of 1-4 mg/L in drinking water.” [1, p 259]
“It is paramount that careful biochemical studies be conducted to de-termine what fluoride concentrations occur in the bone and surroundinginterstitial fluids from exposure to fluoride in drinking water at up to 4mg/L, because bone marrow is the source of the progenitors that producethe immune system cells.” [1, p 259]
“Fluoride appears to have the potential to initiate or promote cancers,particularly of the bone, but the evidence to date is tentative and mixed(Tables 10-4 and 10-5). As noted above, osteosarcoma is of particularconcern as a potential effect of fluoride because of (1) fluoride depositionin bone, (2) the mitogenic effect of fluoride on bone cells, (3) animalresults described above, and (4) pre-1993 publication of some positive,as well as negative, epidemiologic reports on associations of fluoride ex-posure with osteosarcoma risk.” [1, p 286]
“Because fluoride stimulates osteoblast proliferation, there is a theo-retical risk that it might induce a malignant change in the expandingcell population. This has raised concerns that fluoride exposure mightbe an independent risk factor for new osteosarcomas.” [1, p 109]
“Osteosarcoma presents the greatest a priori plausibility as a potentialcancer target site because of fluoride’s deposition in bone, the NTP an-imal study findings of borderline increased osteosarcomas in male rats,and the known mitogenic elect of fluoride on bone cells in culture (seeChapter 5). Principles of cell biology indicate that stimuli for rapid celldivision increase the risks for some of the dividing cells to become malig-nant, either by inducing random transforming events or by unmaskingmalignant cells that previously were in non-dividing states.” [1, p 275]
“Further research on a possible effect of fluoride on bladder cancer riskshould be conducted.” [1, p 288]
“in vivo human genotoxicity studies in U.S. populations or other pop-ulations with nutritional and sociodemographic variables similar to thosein the United States should be conducted.” [1, p 288]
4. Endocrine effects.
“Further effort is necessary to characterise the direct and indirectmechanisms of fluoride’s action on the endocrine system and the fac-tors that determine the response, if any, in a given individual. Suchstudies would address the following. . .
• identification of those factors, endogenous (e.g., age, sex, geneticfactors, or pre-existing disease) or exogenous (e.g., dietary calcium
77
DRAFT
or iodine concentrations, malnutrition), associated with increasedlikelihood of effects of fluoride exposures in individuals;.
• consideration of the impact of multiple contaminants (e.g., fluorideand perchlorate) that affect the same endocrine system or mecha-nism.” [1, p 223]
“The effects of fluoride on various aspects of endocrine function should beexamined particularly with respect to a possible role in the developmentof several diseases or mental states in the United States. Major areasfor investigation include the following:
• thyroid disease (especially in light of decreasing iodine intake by theU.S. population);
• nutritional (calcium-deficiency) rickets;
• calcium metabolism (including measurements of both calcitonin andPTH);
• pineal function (including, but not limited to, melatonin produc-tion);
• development of glucose intolerance and diabetes.” [1, p 224]
5. Thyroid effects
“The chief endocrine effects of fluoride exposures in experimental ani-mals and in humans include decreased thyroid function, increased calci-tonin activity, increased parathyroid hormone activity, secondary hyper-parathyroidism, impaired glucose tolerance, and possible effects on tim-ing of sexual maturity. Some of these effects are associated with fluorideintake that is achievable at fluoride concentrations in drinking water of4 mg/L or less, especially for young children or for individuals with highwater intake. Many of the effects could be considered sub-clinical effects,meaning that they are not adverse health effects. However, recent workon borderline hormonal imbalances and endocrine-disrupting chemicalsindicated that adverse health effects, or increased risks for developingadverse effects, might be associated with seemingly mild imbalances orperturbations in hormone (Summary, page 7) concentrations. Furtherresearch is needed to explore these possibilities.” [1, p 7]
The NRC states, “Biondi et al. (2002) associate sub-clinical thy-roid dysfunction with changes in cardiac function and correspondingincreased risks of heart disease”.
Other reports listed by the NRC show thyroid malfunction is associated with:
“bone demineralization, increased cholesterol, depression, cognitivedysfunction and reduced IQ levels in offspring”.
“Thus, several lines of information indicate an effect of fluoride expo-sure on thyroid function.” [1, p 197]
78
DRAFT
The NRC adds that because of the complexity of thyroid function and other factorsincluding nutrition,
“it is difficult to predict exactly what effects on thyroid function arelikely at what concentration of fluoride exposure and under what cir-cumstances”. [1, p 197]
“Fluoride exposure in humans is associated with elevated TSH con-centrations, increased goitre prevalence, and altered T4 and T3 con-centrations; similar effects on T4 and T3 are reported in experimentalanimals.” [1, p 218]
“In humans, effects on thyroid function were associated with fluorideexposures of 0.05-0.13 mg/kg/day when iodine intake was adequate and0.01-0.03 mg/kg/day when iodine intake was inadequate.” [1, p 218]
“The recent decline in iodine intake in the United States (CDC 2002d;Larsen et al. 2002) could contribute to increased toxicity of fluoride forsome individuals.” [1, p 218]
“Intake of nutrients such as calcium and iodine often is not reportedin studies of fluoride effects. The effects of fluoride on thyroid function,for instance, might depend on whether iodine intake is low, adequate, orhigh, or whether dietary selenium is adequate.” [1, p 222]
Fluoride levels associated with goitre prevalence in some areas studied were lessthan “0.1 to 0.36 mg/L.” According to the American Association of Clinical En-docrinologists, approximately 27,000,000 Americans now have thyroid disorders.
6. Pineal gland effects
“The single animal study of pineal function indicates that fluorideexposure results in altered melatonin production and altered timing ofsexual maturity (Table 8). Whether fluoride affects pineal function inhumans remains to be demonstrated. The two studies of menarcheal agein humans show the possibility of earlier menarche in some individualsexposed to fluoride, but no definitive statement can be made. Recentinformation on the role of the pineal organ in humans suggests that anyagent that affects pineal function could affect human health in a vari-ety of ways, including effects on sexual maturation, calcium metabolism,parathyroid function, postmenopausal osteoporosis, cancer, and psychi-atric disease.” [1, p221-222]
“In summary, evidence of several types indicates that fluoride affectsnormal endocrine function or response; the effects of the fluoride-inducedchanges vary in degree and kind in different individuals. Fluoride istherefore an endocrine disruptor in the broad sense of altering normalendocrine function or response, although probably not in the sense ofmimicking a normal hormone. The mechanisms of action remain to beworked out and appear to include both direct and indirect mechanisms,for example, direct stimulation or inhibition of hormone secretion by in-
79
DRAFT
terference with second messenger function, indirect stimulation or inhi-bition of hormone secretion by effects on things such as calcium balance,and inhibition of peripheral enzymes that are necessary for activation ofthe normal hormone.” [1, p 223]“Further effort is necessary to characterise the direct and indirect
mechanisms of fluoride’s action on the endocrine system and the factorsthat determine the response, if any, in a given individual.” [1, p 223]“The effects of fluoride on various aspects of endocrine function should
be examined further, particularly with respect to a possible role in thedevelopment of several diseases or mental states in the United States.”[1, p 224]
7. Effects on insulin secretion/diabetes
“The conclusion from the available studies is that sufficient fluorideexposure appears to bring about increases in blood glucose or impairedglucose tolerance in some individuals and to increase the severity of sometypes of diabetes. In general, impaired glucose metabolism appears tobe associated with serum or plasma fluoride concentrations of about0.1 mg/L or greater in both animals and humans. In addition, dia-betic individuals will often have higher than normal water intake, andconsequently, will have higher than normal fluoride intake for a givenconcentration of fluoride in drinking water. An estimated 16-20 millionpeople in the U.S. have diabetes mellitus; therefore, any role of fluorideexposure in the development of impaired glucose metabolism or diabetesis potentially significant.” [1, p 217]
8. Neurological effects
“Carefully conducted studies of exposure to fluoride and emerginghealth parameters of interest (e.g., endocrine effects and brain function)should be performed in populations in the United States exposed tovarious concentrations of fluoride.” [1, p 10]“More research is needed to clarify fluoride’s biochemical effects on
the brain.” [1, p 186]“The possibility has been raised by the studies conducted in China
that fluoride can affect intellectual abilities. Thus, studies of popula-tions exposed to different concentrations of fluoride in drinking watershould include measurements of reasoning ability, problem solving, IQ,and short- and long-term memory.”“On the basis of information largely derived from histological, chemi-
cal, and molecular studies, it is apparent that fluorides have the abilityto interfere with the functions of the brain and the body by direct andindirect means.” [1, p 187]“A few epidemiologic studies of Chinese populations have reported IQ
deficits in children exposed to fluoride at 2.5 to 4 mg/L in drinking water.
80
DRAFT
Although the studies lacked sufficient detail for the committee to fullyassess their quality and relevance to U.S. populations, the consistency ofthe results appears significant enough to warrant additional research onthe effects of fluoride on intelligence.” [1, p 6]
“Studies of populations exposed to different concentrations of fluorideshould be undertaken to evaluate neurochemical changes that may beassociated with dementia. Consideration should be given to assessingeffects from chronic exposure, effects that might be delayed or occurlate-in-life, and individual susceptibility.” [1, p 187]
9. Effects related to renal function
“Human kidneys. . . concentrate fluoride as much as 50-fold from plasmato urine. Portions of the renal system may therefore be at higher risk offluoride toxicity than most soft tissues.” [1, p 236]
“Early water fluoridation studies did not carefully assess changes inrenal function.” [1, p 236]
“future studies should be directed toward determining whether kidneystone formation is the most sensitive end point on which to base theMCLG (maximum-contaminant level goal).” [1, p 247]
“On the basis of studies carried out on people living in regions wherethere is endemic fluorosis, ingestion of fluoride at 12 mg per day wouldincrease the risk for some people to develop adverse renal effects.” [1,p 247]
“Thus, more studies are needed on fluoride concentrations in soft tis-sues (e.g., brain, thyroid, kidney) following chronic exposure.” [1, p 83]
“Research is needed on fluoride plasma and bone concentrations inpeople with small to moderate changes in renal function as well as pa-tients with serious renal deficiency. Other potentially sensitive popula-tions should be evaluated, including the elderly, postmenopausal women,and people with altered acid-base balance.” [1, p 83]
“More research is needed on bone concentrations of fluoride in peoplewith altered renal function, as well as other potentially sensitive popu-lations (e.g., the elderly, post-menopausal women, people with alteredacid-balance), to better understand the risks of musculoskeletal effectsin these populations.” [1, p 147]
“Additional studies should be carried out to determine the incidence,prevalence, and severity of renal osteodystrophy in patients with renalimpairments in areas where there is fluoride at up to 4 mg/L in thedrinking water.” [1, p 258]
“The effect of low doses of fluoride on kidney and liver enzyme func-tions in humans needs to be carefully documented in communities ex-posed to different concentrations of fluoride in drinking water.” [1, p 258]
81
DRAFT
10. Better characterisation of biological effects of fluoride and other substances4
“Intake of nutrients such as calcium and iodine often is not reportedin studies of fluoride effects. The effects of fluoride on thyroid function,for instance, might depend on whether iodine intake is low, adequate, orhigh, or whether dietary selenium is adequate.” [1, p 222]
“Better characterisation of exposure to fluoride is needed in epidemi-ology studies investigating potential effects. Important exposure aspectsof such studies would include the following: collecting data on general di-etary status and dietary factors that could influence exposure or effects,such as calcium, iodine, and aluminium intakes.” [1, p 72]
“The possibility of biological effects of SiF6, as opposed to free fluoride
ion, should be examined.” [1, p 72]
“The biological effects of aluminofluoride complexes should be re-searched further, including the conditions (exposure conditions and phys-iological conditions) under which the complexes can be expected to occurand to have biological effects.” [1, p 72]
“histopathological changes similar to those traditionally associatedwith Alzheimer’s disease in people have been seen in rats chronicallyexposed to A1F.” [1, p 178]
“Fluorides also increase the production of free radicals in the brainthrough several different biological pathways. These changes have abearing on the possibility that fluorides act to increase the risk of devel-oping Alzheimer’s disease.” [1, p 186]
“Available information now indicates a role for aluminium in the in-teraction of fluoride on the second messenger system; thus, differencesin aluminium exposure might explain some of the differences in responseto fluoride exposures among individuals and populations.” [1, p 222]
“With the increasing prevalence of acid rain, metal ions such as alu-minium become more soluble and enter our day-to-day environment; theopportunity for bio-active forms of A1F to exist has increased in the past100 years. Human exposure to aluminofluorides can occur when a per-son ingests both a fluoride source (e.g., fluoride in drinking water) andan aluminium source; sources of human exposure to aluminium includedrinking water, tea, food residues, infant formula, aluminium- contain-ing antacids or medications, deodorants, cosmetics, and glassware.” [1,p 42]
“Further research should include characterisation of both the exposureconditions and the physiological conditions (for fluoride and for alu-minium or beryllium) under which aluminofluoride and beryllofluoridecomplexes can be expected to occur in humans as well as the biologicaleffects that could result.” [1, p 42]
4e.g. aluminium
82
DRAFT
“Another possible explanation for increased blood lead concentrationswhich has not been examined is the effect of fluoride intake on calciummetabolism; a review by Goyer (1995) indicates that higher blood andtissue concentrations of lead occur when the diet is low in calcium. In-creased fluoride exposure appears to increase the dietary requirementfor calcium (see Chapter 8); in addition, the substitution of tap-waterbased beverages (e.g., soft drinks or reconstituted juices) for dairy prod-ucts would result in both increased fluoride intake and decreased calciumintake.” [1, p 43]
“Given the expected presence of fluoride ion (from any fluoridationsource) and silica (native to the water) in any fluoridated tap water, itwould be useful to examine what happens when that tap water is usedto make acidic beverages or products (commercially or in homes), espe-cially fruit juice from concentrate, tea, and soft drinks. Although neitherUrbansky (2002) nor Morris (2004) discusses such beverages, both indi-cate that at pH <5, SiF
62- would be present, so it seems reasonable to
expect that some SiF62- would be present in acidic beverages but not
in the tap water used to prepare the beverages. Consumption rates ofthese beverages are high for many people, and therefore the possibilityof biological effects of SiF
62-, as opposed to free fluoride ion, should be
examined.” [1, p 44]
“More work is needed on the potential for release of fluoride by themetabolism of organofluorines.” p83
11. Birth defects
“The possible association of cytogenetic effects with fluoride exposuresuggests that Down’s syndrome is a biologically plausible outcome ofexposure.” [1, p 170]
“A reanalysis of data on Down’s syndrome and fluoride by Takahashi(1998) suggested a possible association in children born to young moth-ers. A case-control study of the incidence of Down’s syndrome in youngwomen and fluoride exposure would be useful for addressing that issue.However, it may be particularly difficult to study the incidence of Down’ssyndrome today given increased foetal genetic testing and concerns withconfidentiality.” [1, p 172]
“The relationship between fertility and fluoride requires additionalstudy.” [1, p 161]
“Two small studies have raised the possibility of an increased incidenceof spina bifida occulta in fluorosis-prone areas in India; larger, well-controlled studies are needed to evaluate that possibility further.” [1,p 164]
12. Effects on gastrointestinal system
83
DRAFT
“The numerous fluoridation studies in the past failed to rigorouslytest for changes in GI symptoms and there are no studies on drinkingwater containing fluoride at 4 mg/L in which GI symptoms were carefullydocumented.” [1, p 230]
“GI effects appear to have been rarely evaluated in the fluoride sup-plement studies that followed the early ones in the 1950s and 1960s.” [1,p 231]
“The table suggests that fluoride at 4 mg/L in the drinking water re-sults in approximately 1% of the population experiencing GI symptoms.”[1, p 231]
“Whether fluoride activates G proteins in the gut epithelium at verylow doses (e.g., from fluoridated water at 4.0 mg/L) and has signifi-cant effects on the gut cell chemistry must be examined in biochemicalstudies.” [1, p 236]
“There are a few case reports of GI upset in subjects exposed to drink-ing water fluoridated at 1 mg/L. Those effects were observed in only asmall number of cases, which suggest hypersensitivity. However, theavailable data are not robust enough to determine whether that is thecase.” [1, p 250]
“Studies are needed to evaluate gastric responses to fluoride from nat-ural sources at concentrations up to 4 mg/L and from artificial sources.”[1, p 258]
8 Irish Dentists Opposing Fluoridation
8.1 I.D.O.F. Policy on Water Fluoridation
5 Most dentists would refuse to prescribe for a patient he or she has never met, whosemedical history he or she does not know, a substance which is intended to create bodilychange; with the advice, take as much as you like but you will take it for the rest of yourlife, because some children have tooth decay. This is the water fluoridation ethos. IrishDentists Opposing Fluoridation is a support group for fellow dental professionals whowish to express their opposition to the practice of mass medicating our drinking waterwith fluoride. Our primary aim is to highlight the undemocratic, unethical and unsafenature of fluoridation in Ireland. As dentists, we have to lead the way in reducing thepublic’s exposure to this toxic chemical. A chemical which, the Irish Medicines Boarddeclares is not registered as a medicine, is unlicensed and has never been proved safeor effective for use on humans. We are opposed to water fluoridation for the followingreasons:
5Original Policy statement link http://homepage.eircom.net/~aud/home.htm
84
DRAFT
8.1.1 Infringement of our human rights
Fluoridation is compulsory. There is no freedom to choose with this form of medication.The Irish government has never requested the free informed consent of the populationto give them fluoride in their water supply. This is contrary to the Council of Europe’s’Convention on Human Rights and Bio-medicine’ (1997).
8.1.2 Dental Fluorosis
Dental fluorosis is tooth damage caused by swallowing fluoride. Current estimates, ofdental fluorosis, state that between 24-50% of all Irish children and teenagers have someform of this condition.
8.1.3 Health damage
There are numerous international scientific studies linking fluoride/fluoridation withserious health conditions such as hip fractures, cancer, osteoporosis, thyroid dysfunction,neurological impairment and irritable bowel syndrome.
8.1.4 Summary
The York Review of water fluoridation, “. . . conducted by an independent group to thehighest international scientific standards. . . ”, published its findings in September 2000.One of the main conclusions of this review surprised many; “given the level of interestsurrounding the issue of public water fluoridation, it is surprising to find that littlehigh quality research has been undertaken”. In Ireland, there has never been a healthstudy in forty-two years of artificial water fluoridation. This is in breach of the Health(Fluoridation of Water Supplies) Act 1960, section 6, and there is public concern thatthe local health effects in Ireland are unknown. The Department of Health continue toreassure the public, “major reviews of the evidence by leading medical scientists haveshown time and time again that the use of fluoride in drinking water at 1 part per millionis safe to human health”. Fluoridation became mandatory in the early sixties and aninvestigation in this era concluded that fluoride was safe and had no adverse healtheffects. However, over forty years on, the scientific climate has changed considerably.Since then, there have been innumerable studies, investigations and developments inartificial water fluoridation. The conclusions in many cases are contradictory but it isimportant to consider all aspects of these developments, both pro- and anti-fluoridation.
One adverse effect that both sides agree on is dental fluorosis. Descriptions of dentalfluorosis range from “. . . a cosmetic issue. . . ” to “. . . the first readily detectable symptomof previous chronic fluoride poisoning”. Water fluoridation causes dental fluorosis ina significant proportion of the population. Moreover, the most important and widelydisregarded fact about dental fluorosis is this: “no safe established daily intake of fluorideexists”. As a marker for past fluoride overexposure, it is important to recognise the levelsof this condition in the population. This dental condition is seen as, “. . . white spots on
85
DRAFT
the teeth, surface pitting and in severe cases there is brown staining”, according to Dr.Gerard Gavin, Chief Dental Officer, Department of Health.There is much confusion about the estimated levels of dental fluorosis in Ireland.
These figures range from 10–50%. The York Review concluded that 48% of a fluoridatedpopulation will develop dental fluorosis. Moreover, 12.5% of a fluoridated population willhave such notable fluorosis that will probably require dental treatment. Dental fluorosisis increasing in Ireland. Since the introduction of water fluoridation in the 1960s, therehas been an increase in the number of fluoride sources (total fluoride intake) and theseare all added risk factors for dental fluorosis. Fluoride toothpaste introduced in the1970s and additionally, fluoride supplements, dental products, tea, fruit juices and manyother sources contribute to our total fluoride burden.With nearly half of the population likely to have this fluoride disorder there is concern
that we should be reducing our fluoride intake not extending water fluoridation. But theDepartment of Health declares this level of dental fluorosis is an acceptable cost/benefitresult (i.e. increased dental fluorosis against reduction in tooth decay). However, asdemonstrated in the previous chapter, the decay reduction from water fluoridation isless significant than previously estimated. Thus, the ethical question is: is a limitedtooth decay reduction balanced by exposing nearly half the population to a new oraldisease (dental fluorosis)?The bone effects of water fluoridation are much more controversial. Fluoride exerts
effects on mainly skeletal tissues e.g. bones and teeth. There are many studies investi-gating the relationship between fluoridation and hip fracture. Of 18 studies since 1990,10 show a positive association between fluoride exposure and hip fracture, however 8do not. The York Review concluded on this issue, “. . . there is no clear association ofhip fracture with water fluoridation”. The Department of Health point to another bonedisorder, linked to water fluoride levels, called skeletal fluorosis. Skeletal fluorosis is adegenerative bone disorder, which in its early stages can be misdiagnosed as rheuma-toid or osteo-arthritis. The World Health Organisation, clarifies that, “skeletal fluorosis(with adverse changes in bone) is observed when drinking water contains 3–6mg/litre”.Ireland’s drinking water contains 0.8–1mg/litre. Considering total fluoride exposure hasincreased over recent years, from other sources — fluoride toothpaste, tea and fruitdrinks, there is growing concern that there is not an adequate margin of safety withwater fluoridation.The Royal College of Physicians of Ireland affirms “. . . that there is no evidence that
chronic exposure to concentrations of fluoride reported to be greater than 2mg/litre indrinking water increase human cancer mortality or incidence”. The York Review alsofound no clear association. There is concern that the York Review has limitations asthey excluded animal studies. Yet, there are many animal studies linking fluoride andcancer.A landmark court case in the United States, reviewing the pros and cons of water
fluoridation, included both animal and epidemiological studies with particular attentionto links between fluoridation and cancer. On the weight of the evidence, Judge Flahertyissued an injunction against water fluoridation. However, the case was overturned onjurisdictional grounds but the findings remain undisturbed. One related outcome of this
86
DRAFT
case was that following a review by the Ministry of the Environment in Quebec, Canada,fluoridation there was suspended. Quebec remains unfluoridated today.
In addition, there is conflicting evidence as regards the link between fluoridation andosteosarcoma. Osteosarcoma is a rare cancer of bone but is one of the most prevalentcancers in young males. Other cancers studied (e.g. uterine cancer), showing a positiverelationship have been criticised on methodology.
The blood brain barrier, until recently, was believed to be impervious to fluoride.This is now in question. Some neurological implications for water fluoridation havebeen cited. These animal studies demonstrate behavioural change but are contendedfor using high levels of fluoride. Several studies have proposed a link between fluorideand Alzheimers disease. A recent study relating to blood lead levels in children founda positive correlation between these elevated levels and the fluoridating agent used.Interestingly, Ireland uses the same silico-fluoride chemical for water fluoridation. Therehas been a rebuttal paper questioning this study.
Other linked adverse health effects include the action of fluoride on the pineal gland,enzyme activity, the thyroid gland and fertility and mutagenicity. Other related butcontended disorders include Down’s syndrome, Renal Disease, allergic sensitivity andinfant mortality.
There is much controversy over the health implications of water fluoridation, excludingdental fluorosis. The Department of Health in Ireland disputes all other adverse healtheffects despite no health studies in Ireland. The York Review concluded that there wasno association between fluoridation/bone fracture and fluoridation/cancer based on theavailable evidence. Other adverse effects studied did not provide sufficient evidence.But, as discussed, there were limitations within the York Review.
A number of European regulatory authorities and non-governmental organisationshave introduced the concept of the Precautionary Principle. The Irish government re-cently cited this principle in regards to vaccination safety. The Precautionary Principlestates that if there is any doubt about the potential harm that exposure to a chemi-cal substance may cause, then governments should not wait for complete and definitiveproof, but instead ask several fundamental questions:
1. Does the weight of evidence from all scientific studies (biochemical, animal, tissueculture, human) suggest we have a problem?
2. How serious would that problem be if we continue to expose a whole populationand cause harm?
3. How important is the goal that this exposure means to accomplish?
4. Are there available alternatives to the exposure that achieves the same goal?
Water fluoridation fails on all four of these grounds. Finally, Professor Sheldon, (Chair-man of the Advisory Group of the York Review) sums up, “the review team was surprisedthat in spite of the large number of studies carried out over several decades there is adearth of reliable evidence with which to inform policy. Until high quality studies are
87
DRAFT
undertaken providing more definite evidence, there will continue to be legitimate scien-tific controversy over the likely effects and costs of water fluoridation”. There are noplans from the Department of Health, for general health studies in Ireland despite thecurrent legislation requiring them.
9 Glossary
Glossary
prophylactic Preventive medicine or preventive care consists of measures taken to pre-vent diseases, (or injuries) rather than curing them or treating their symptoms..4, 88
10 Bibliography
1. National Archives, M102/3
2. National Archives, M102/3
3. -
4. National Archives, M102/3
5. Dail Report (5 April 1959), 1744
6. -
7. Committee Report, Health & Children (20th July 2000
8. National Archives, M102/10
9. National Archives, M102/10
10. Dept of Health Archives, National Review of Policy on Dental Services (year?
11. Paul Beirne, Ireland’s Mandatory Fluoridation Policy: an Historical Analysis ofthe Policy Process, (Dissertation for Masters Degree in Dental Public Health April1999 National University of Ireland, Cork
12. Department of Health Archives, Circular No. 14/55 (March 1955)
13. Bock (1983)
14. British Medical Journal (26 February 1955)
15. Extract from UK Mission Report (1953), Department of Health Archives
16. UCD Archives, 67/304 (1)
88
DRAFT
17. Fluorine Consultative Council Report (1958)
18. National Archives, M102/48
19. John Gormley TD, Parliamentary Question
20. National Archives, SI6470
21. UCD Archives, 67/304(1
22. Dail Committee on Health & Children (20 July 2000)
23. Health Bill, Dail Report (5 April 1959), 1743
24. Dail Report (5th April ???year), 1752
25. Fluoridation in Water Bill (5 April 1960),1749
26. Dail Report (5th April ???year), 1752
27. Dail Report (5th April ???year), 1752
28. Dail Report (5th April ???year), 1752
29. Health Bill (5 April 1960), 1755
30. Dail Debates (27 October 1960)
31. Dail Debates (27 October 1960)
32. Seanad Debates (21 December 1960)
33. Dail Debates (23 November 1960)
34. Irish Independent (25 April 1962)
35. UCD Archives, 67-68
36. Fluoridation of Public Water Supplies in Ireland, Department of Health and Chil-dren, 12th April 2000:
37. Micheal Martin TD quoted on The Water Fluoridation Debate, TV3’s 20/20, Jan-uary 12th 2001
38. A Systematic Review of Public Water Fluoridation, NHS Centre for Reviews andDissemination, University of York, September 2000
39. Oral Health in Ireland, Oral Health Services Research Centre, National Universityof Ireland Cork and the Dental Health Foundation, Ireland, First Edition 1999: 1
40. Ibid: 1
89
DRAFT
41. Dr. Gerard Gavin quoted on The Water Fluoridation Debate, TV3’s 20/20, Jan-uary 12th 2001
42. Professor D. O’Mullane, Presentation to the Joint Committee on Health and Chil-dren, 20th July 2000
43. Fluoridation of Public Water Supplies in Ireland, Department of Health and Chil-dren,l2th April 2000:
44. Children’s Dental Health in the Western Health Board Region,1991-1992, con-ducted in collaboration with The Oral Health Services Research Centre, UniversityCollege Cork, March 1994:1
45. Mid-Western Health Board Survey of Oral Health Children and Adolescents 1997,directed by the Oral Health Services Research Centre, University College Cork: 1
46. Ibid: 1
47. Dental Health Foundation Ireland , Water Fluoridation, Questions and Answers,May 2000:
48. Micheal Martin TD, speaking on RTE’s Primetime, 22nd February 2000
49. Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto, Canada.Presentation to Joint Committee on Health and Children. 12th October 2000
50. WHOOral Health Country/ Area Profile Programme, Department of Non-communicableDiseases Surveillance/Oral Health, WHO Collaborating Centre, Malmo University,Sweden.
http://www.whocollab.od.mah.se/euro.html
51. Marthaler T.M. The Prevalence of Dental Caries in Europe 1990-1995. Caries Res.1996; 30: 237-255
52. Mid-Western Health Board Survey of Oral Health Children and Adolescents 1997,directed by the Oral Health Services Research Centre, University College Cork: 1
53. Diesendorf, M. (1986). The Mystery of Declining Tooth Decay. Nature, 322,125-129
54. R.L. Glass, “Secular Changes in Caries Prevalence in Two Massachusetts Towns”,Caries Research, Volume 15, pp. 445-450 (1981
55. Water Fluoridation and Public Health, Faculty of Public Health Medicine, RoyalCollege of Physicians of Ireland, (October 1999): 1
56. Diesendorf, M. (1986). The Mystery of Declining Tooth Decay. Nature, 322,125-129
90
DRAFT
57. Bratthall D, Hansel Peterson G, Sundberg H. (1996) Reasons for the caries decline.What do the experts believe? Euro J Oral Science 104:416-42
58. Birkeland JM, Haugejorden 0, Ramm Von Der Fehr F. Some factors associatedwith the caries decline among Norwegian children and adolescents: age-specificand cohort analysis. Caries Research. 2000 Mar-Apr;34 (2):109-16
59. Krasse B. From the art of filling teeth to the science of dental caries prevention: apersonal review. Journal of Public Health Dentistry. 1996; 56 (5spec No) 271-7
60. Colquhoun J, Child Dental Health Differences in New Zealand, Community HealthStudies 1987, X:2,85-90
61. Colquhoun J. Fluorides and the decline in tooth decay in New Zealand. Fluoride26 125- 134 199
62. Colquhoun J. “Why I Changed My Mind About Water Fluoridation”, Fluoride31(2), 1998, pp 103-118 /par http://www.fluoride-journal.com/98-31-2/312103.htm
63. de Liefde B, The Decline of caries in New Zealand over the past 40 years, NZDental Journal, 1998 Sept 94 (471: 109-1
64. Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto, Canada.Presentation to Joint Committee on Health and Children. 12th October 2000
65. Fluoridation of Public Water Supplies in Ireland, Department of Health and Chil-dren,l2th April 2000:
66. Sugar Consumption Kg/ Capita/ Annual, WHO Oral Health Country/ Area Pro-file Programme, Department of Non-communicable Diseases Surveillance/Oral Health,Who Collaborating Centre, Malmo University, Sweden
67. Marthaler T.M. The Prevalence of dental caries in Europe 1990-1995, Caries Res.,1996; 30:237-255
68. Dr. Liz Cullen, Presentation to the Joint Committee on Health and Children,20thJuly 2000
69. Fluoridation of Public Water Supplies in Ireland, Department of Health and Chil-dren,l2th April 2000:
70. Water Fluoridation and Public Health, Faculty of Public Health Medicine, RoyalCollege of Physicians of Ireland, (October 1999): 1
71. O’Mullane., D., PhD, Whelton, HP., PhD, Costelloe, P., BDS, Clarke, D., BDS:The Results of Water Fluoridation in Ireland’; Journal of Pubic Health Dentistry1996; Vol. 56, No. 5, Special Issue: 259-26
72. ibid: 26
91
DRAFT
73. Blinkhorn AS., Attwood D., Gavin G., O’Hickey S. Joint epidemiological surveyon dental health of 12 year-year-old school children in Dublin and Glasgow. Com-munity Dentistry and Oral Epidemiology 1992; 20:307-30
74. Dr. Gerard Gavin, Chief Dental Officer Department of Health, Presentation toJoint Committee on Health and Children, 20th July 2000
75. Fluoridation of Public Water Supplies in Ireland, Department of Health and Chil-dren,l2th April 2000:
76. Downer M., Blinkhorn A., Holt R., Wight*C., Attwood W. Dental Caries Experi-ence and Defects of Dental Enamel Among 12 year old Children in North London,Edinburgh, Glasgow and Dublin. Community Dentistry & Oral Epidemiology1994; 22: 283-28
77. Water Fluoridation and Public Health, ibi
78. A Systematic Review of Public Water Fluoridation, NHS Centre for Reviews andDissemination, University of York, September 2000
79. Systematic Review of Water Fluoridation, McDonagh et al, British Medical Journal2000; 321:855-859 (7 October
80. A Systematic Review of Public Water Fluoridation, NHS Centre for Reviews andDissemination, University of York, September 2000
81. Ibid: xi
82. Ibid: 2
83. Ibid: 6
84. Connett P., Ph.D., A Critique of the York Review.
http://www.fluoridealert.org/york-critique.htm
85. Kumar,J V., E. L. Green, et al. (1989). “Trends in dental fluorosis and dentalcaries prevalences in Newburgh and Kingston, NY.” AM J Public Health 79(5):565-
86. Kumar, J.V., and P.A. Swango et al. (1998 a). “Changes in dental fluorosis anddental caries in Newburgh and Kingston, New York.” American Journal of PublicHealth 88 (12): 1866-187
87. Connett P., Ph.D., A Critique of the York Review.
http://www.fluoridealert.org/c-york.htm
92
DRAFT
88. British Dental Association, Press Release, Health Organisations Welcome WaterFluoridation Review and Call on Government to Act on Pledge to Change Law,6th October 2000.
http://www.derweb.co.uk/bfs/york_rev.htm
89. Carnell, D. Water Fluoridation. BMJ, (7 October),
http://www.bmj.com/content/321/7265/904.2.full
90. Children’s Dental Health in Ireland 1984, A survey conducted on behalf of TheMinister for Health by University College Cork
91. Dr. Gerard Gavin, Chief Dental Officer Department of Health, Presentation toJoint Committee on Health and Children, 20th July 2000
92. Mid-Western Health Board, Survey of Oral Health of Children and Adolescents1997, directed by the Oral Health Services Research Centre, University CollegeCork
93. Ibid: 16
94. Ibid: 15
95. North Eastern Health Board Oral Health of Children and Adolescents 1995, Di-rected by the Oral Health Service Research Centre, University College Cork: 14
96. Ibid: 16
97. Ibid: 1
98. Southern Health Board Oral Health of Children and Adolescents1995, Directed bythe Oral Health Service Research Centre University College Cork
99. Ibid: 16
100. Dr. Gerard Gavin, Chief Dental Officer Department of Health, Presentation toJoint Committee on Health and Children, 20th July 2000
101. Whelton, H., O’Mullane, D. The Effectiveness of Water Fluoridation in Ireland,Oral Health Services Research Centre, University Dental School, Cork
102. Children’s Dental Health in Ireland 1984, A survey conducted on behalf of TheMinister for Health by University College Cork
103. Mid-Western Health Board, Survey of Oral Health of Children and Adolescents1997, directed by the Oral Health Services Research Centre, University CollegeCork
104. Marthaler T.M The Prevalence of Dental Caries In Europe 1990-1995 Caries Re-search 1996; 30:237-25
93
DRAFT
105. Sutton, P. (1996) The Greatest Fraud: Fluoridation A Factual Book, Kurunda PtyCo. PO Box 22, Lorne, Australia 3232
106. Ziegelbecker, R. (1981). Fluoride, 14, 123-12
107. Ziegelbecker, (2000). Review of the York Repor
108. Connett, P. PhD. (2000), A Statement of Concern
http://www.fluoridealert.org/fluoride-statement.htm
109. Yiamouyiannis, J, Fluoride The Ageing Factor, Health Action Press,1993
110. Professor D. O’Mullane, Presentation to the Joint Committee on Health and Chil-dren, 20th July 2000
111. Galagon, D. “Climate and Controlled Fluoridation”, Journal of the American Den-tal Association, Volume 47, pp. 159-170 (1953
112. Zimmerman, E “Oral Aspects of Excessive Fluorides in a Water Supply”, Journalof the American Dental Association, Volume 50, pp. 272-277 (1955
113. Edward Sweeney, et al., “Effect of Alloxan Diabetes on Fluoride Retention andCaries Incidences in Rats”, Journal of Dental Research, Volume 41, No. 4, pp.866-874 (1962
114. J.L. Hardwick and D.M. Bunting, “Effects of Fluoridation of Drinking Water orof a Cariogenic Diet on Caries Experience of Rats”, Journal of Dental Research,Volume 50 (Supplement to No 5), p, 1212. (1971
115. Yoshitsugu Imai, “Relation Between Fluoride Concentration in Drinking Waterand Dental Caries in Japan”, Kohu Eisei Gakkai Zassihi, Volume 22, No. 2, pp.144-196 (1972
116. Colquhoun J, Child Dental Health Differences in New Zealand, Community HealthStudies 1987, X:2,85-90
117. A.S Gray, “Fluoridation: Time for a New Baseline?” Journal of the CanadianDental Association, Volume 53, pp. 763-765 (1987
118. Hildebolt CF, Elvin-Lewis M, Molnar S, McKee JK, Perkins MD, Young KL, Cariesprevalences among geochemical regions of Missouri, Am J Phys Anthropol, 1989Jan,78 (1), 79-9
119. Yiamouyiannis, J.A. (1990). Water Fluoridation and Tooth Decay: Results fromthe 1986- 87 National Survey of U.S. Schoolchildren. Fluoride, 23, 55-67
120. Brunelle, J.A and Carlos, J.P. (1990). J. Dent. Res 69, (Special Edition), 723-72
94
DRAFT
121. Teotia SPS, Teotia M, Dental caries: a disorder of high fluoride and low dietarycalcium interactions (30 years of personal research), Fluoride,1994 April, 27:2, 59-66
122. Yiamouyiannis, J, Fluoride The Ageing Factor, Health Action Press, 1993: 122
123. A Systematic Review of Public Water Fluoridation, NHS Centre for Reviews andDissemination, University of York, September 2000: 88
124. Waldbott,GL et al. Fluoridation, The Great Dilemma, Laurence, XS, CoronadoPress, 1978, p295
125. O’Mullane., D., PhD, Whelton, HP., PhD, Costelloe, P., BDS, Clarke, D., BDS:’The Results of Water Fluoridation in Ireland’; Journal of Pubic Health Dentistry1996; Vol. 56, No. 5, Special Issue: 259-26
126. Marthaler T.M. The Prevalence of Dental Caries in Europe 1990-1995. CariesResearch. 1996; 30: 237-255
127. Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto, Canada.Presentation to Joint Committee on Health and Children. 12th October 2000
128. Kunzel VW. (Cross-sectional comparisons of the median eruption time for perma-nent teeth in children from fluoride poor and optimally fluoridated areas. StomatolDDR. 1976 May; 5:310-21
129. Virtanen JI, Bloigu RS, Larmas MA. Timing of eruption of permanent teeth:standard Finnish patients documents. Community Dent Oral Epidemiol. 1994Oct; 22 (5 pt 1):286-8
130. Campagna L, Tsamtouris A, Kavadia K. Fluoridated drinking water and matura-tion of permanent teeth at age 12. J Clin Pediatr Dent. 1995 Spring; 19(3):225-8
131. Nadler GL: Ealier dental maturation: fact or fiction? Angle Orthod 1998 Dec; 68(6): 535-8
132. American Dental Association.
http://www.ada.org/public/yopics/fluoride/facts-benefit.html#
133. Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto, Canada.Presentation to Joint Committee on Health and Children. 12th October 2000
134. A Systematic Review of Public Water Fluoridation, NHS Centre for Reviews andDissemination, University of York, September 2000: 1
135. Kunzel W, Fisher T, Lorenz R, Bruhmann S (2000), Decline of caries prevalenceafter the cessation of water fluoridation in the former East Germany, CommunityDent Oral Epidemiol, 2000 Oct, 28(5): 382-
95
DRAFT
136. Seppa I, Karkkainen S, Hausen H, Caries Frequency in Permanent teeth Beforeand After Discontinuation of Water Fluoridation in Kuopio, Finland. Abstractfrom Community Dentistry & Oral Epidemiology 26 (4) 256-262 199
137. Seppa L, Karkkainen S, Hausen H. Caries Trends 1992-1998 in Two Low-FluorideFinnish Towns Formerly with and without Fluoridation, Caries Research 2000 Nov;34(6):462-46
138. Maupome G, Clark DC, Levy SM, Berkowitz J. Patterns of Dental Caries followingthe cessation of water fluoridation. Community Dent Oral Epidemiol 2001 Feb; 29(1):37-47
139. Burt BA, Keels MA, Heller KE The Effects of a break in water fluoridation on thedevelopment of dental caries and fluorosis. J. Dent Research 2000 Feb;79(2):761-
140. Kunzel W, Kischer T. Caries prevalence after cessation of water fluoridation in LaSalud, Cuba. Caries Research 2000 Jan-Feb;34(1):20-
141. Water Fluoridation and Public Health, Faculty of Public Health Medicine, RoyalCollege of Physicians of Ireland, October 1999; 1
142. A Systematic Review of Public Water Fluoridation, NHS Centre for Reviews andDissemination, University of York, September 2000: 6
143. Water Fluoridation and Public Health, Faculty of Public Health Medicine, RoyalCollege of Physicians of Ireland, (October 1999): 15
144. TheWater Fluoridation Debate, Poison or Protection, by Jim Power, Irishhealth.com.Feb200
145. Dr. Gerard Gavin, Chief Dental Officer Department of Health, Presentation toJoint Committee on Health and Children, 20th July 2000
146. The Water Fluoridation Debate, TV3, 20/20 January 200
147. Micheal Martin TD, Primtime, RTE, February 2000
148. Mid-Western Health Board Survey of Oral Health Children and Adolescents 1997,directed by the Oral Health Services Research Centre, University College Cork: 5
149. North Eastern Health Board Oral Health of Children and Adolescents 1995, Di-rected by the Oral Health Service Research Centre, University College Cork: 33
150. Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto, Canada.Presentation to Joint Committee on Health and Children. 12th October 2000
151. Felle, Thomas. Eight Year Wait for Dentists, Evening Herald, 30th November,2000:2
96
DRAFT
152. Professor D. O’Mullane, Presentation to the Joint Committee on Health and Chil-dren, 20th July 2000
153. Fluoridation of Public Water Supplies in Ireland, Department of Health and Chil-dren,l2th April 2000; pg 4
154. Dr. Maire O’Connor,The Water Fluoridation Debate, TV3’s, 20/20, January 12th2001
155. Water Fluoridation and Public Health, Faculty of Public Health Medicine, RoyalCollege of Physicians of Ireland, (October 1999): 1
156. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
157. Letter from Professor Trevor A. Sheldon, Head of Department, Department ofHealth Studies, York. 3/1/200
158. Letter from Professor Trevor A. Sheldon, Head of Department, Department ofHealth Studies, York. 3/1/200
159. Letter from Professor Trevor A. Sheldon, Head of Department, Department ofHealth Studies, York. 3/1/200
160. Department of Health, Hawkins House, Dublin. Fluoridation of Public WaterSupplies in Ireland, 12/4/2000
161. Dr. Gerard Gavin, Chief Dental Officer, Dept. of Health, presentation to the DailCommittee on Health and Children. 20/7/2000
162. Guidelines for Drinking Water Quality, 2nd ed. Vol.2. Health criteria and othersupporting information. Geneva, World Health Organisation, 1996.pp. 231-237
163. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
164. Health (fluoridation of water supplies) Act 1960, section 6
165. Gavin, 20/7/2000
166. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health. October 1999
167. Ibid
168. Gavin, 20/7/2000
169. TV3 - 20/20 documentary. Hard To Swallow-The Water Fluoridation Debate.12/1/2001
97
DRAFT
170. Dr. Gavin, 20/7/2000
171. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
172. Dr. Geoffrey Smith. New Scientist, May 5, 1983
173. British Fluoridation Society briefing. Dental Fluorosis in Perspective: The Good,The Bad and The Ugly. November 1997
174. Department of Health and Children. Submission to Joint Oireachtas Commit-tee on Health and Children on Fluoridation of Public Water Supplies in Ireland.20/7/2000
175. Fluoride Free Water Ireland. Dental Fluorosis Register.
http://homepage.eircom.net/~fluoridefree/register.htm
176. Fejerskov O, Manji, F, and Baelum, V. Dent. Res., 1990; 69: 692-700
177. Giambro NJ, Prostak K., and Den Besten PK., Caries Res., 1995; 29: 251-257
178. Feyerskov O, Ekstrand, J., Burt B.A. Fluoride in Dentistry. Munksgaard Text-book. 1996; Chapter 8: 124
179. Susheela AK, Madhu Bhatnagar, Gnanasundram N and Saraswathy TR. CurrentScience. Dec. 1999; Vol. 77, No. 12: 1677-1681
180. Feyerskov O, Ekstrand, J., Burt B.A. Fluoride in Dentistry. Munksgaard Text-book. 1996; Chapter 8: 113
181. Dr. Gavin. 20/7/2000
182. Black G. V.,and McKay F. Mottled teeth: an endemic developmental imperfectionof the enamel heretofore unknown in the literature of dentistry. Dental Cosmos,1916; 58(2): pp. 129-256
183. Churchill H. V., The occurrence of fluorides is some waters of the United States.J Am Water Works Assn. 1931; 23: pp. 1399-1403
184. Health Effects of Ingested Fluoride, Subcommittee on Health Effects of IngestedFluoride, Committee on Toxicology, Board on Environmental Studies and Toxi-cology, Commission on Life Sciences, National Research Council, August 1993 p37
185. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
186. Ibid
98
DRAFT
187. Harold C. Hodge, Ph.D., The Safety of Fluoride Tablets or Drops, ContinuingEvaluation of the Use of Fluorides, AAAS Symposium, Boulder, CO, WestviewPress, 1979 pp 255-256
188. Dr. Gavin, 20/7/2000
189. Myers HM. Dose Response between water fluoride levels and the category of ques-tionable dental fluorosis. Community Dent Oral Epidemiology. 1983; 11:109-112
190. TV3 - 20/20 documentary. Hard To Swallow-The Water Fluoridation Debate.12/1/2001
191. Professor Denis O’ Mullane. Controversy Water Fluoridation. Irish MedicalJournal. 2000; 93, no. 9
192. Feyerskov O, Ekstrand J, Burt BA. Fluoride in Dentistry. Munksgaard Textbook.1996; Chapter 8: 141
193. Professor Denis O’Mullane, 20/7/2000
194. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
195. Ibid
196. Professor Denis O’Mullane. 20/7/2000
197. Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto, pastpresident of Canadian Association of Dental Research, presentation to the JointCommittee on Health and Children. 12/10/2000
198. Dr. Gerard Gavin, 20/7/200
199. Fejerskov O.,Manji F. and Baelum V. The Nature and Mechanisms of Dental Flu-orosis in Man, Journal Dental Research. 1990; Feb., 69(special issue): 692-700
200. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
201. Kavanagh D, Renehan J. Fluoride in Tea Its Dental Significance: A review. Jour-nal of Irish Dental Association. 1998; Vol. 44. No. 4: pp100-10
202. Department of Health and Human Services. Review of Fluoride Benefits and Risks.Feb. 1991: P. 17
203. Kavanagh D, Renehan J. Fluoride in Tea Its Dental Significance: A review. Jour-nal of Irish Dental Association. 1998; Vol. 44. No. 4: pp100-105
204. Duckworth SC, Duckworth R. The ingestion of fluoride in tea. Brit Dent J. 1978;145: 368-370
99
DRAFT
205. Jenkins GN. Fluoride intake and its safety among heavy tea drinkers in a Britishfluoridated city. roc Finnish Dent Soc. 1991; 87: 571-579
206. Kavanagh D, Renehan J. Fluoride in Tea Its Dental Significance: A review. Jour-nal of Irish Dental Association. 1998; Vol. 44. No. 4: pp100-105
207. Kiritsy MC, Levy SM, Warren JJ, Gira-Chowdhury N. Hellmann JR, Marshall T.Assessing fluoride concentrations of juices and juice-flavoured drinks. J Amer DentJ Ass 1996; 127: 895-901
208. Pang DT, Phillips CL, Bawden JW. Fluoride intake from beverage consumptionin a sample of North Carolina children. J Dent Res. 1992; 71: 1382-1388
209. Kiritsy MC, Levy SM, Warren JJ, Gira-Chowdhury N. Heilmann JR, Marshall T.Assessing fluoride concentrations of juices and juice-flavoured drinks. J Amer DentJ Ass 1996; 127: 895-901
210. Heilman JR, Kiritsy MC, Levy SM, Wefel JS. Assessing fluoride levels of carbon-ated soft drinks. J AM Dent Assoc. 1999; 130: 1593-1539
211. Jan G. Stannard, et al. “Fluoride Levels and Fluoride Contamination of FruitJuices,” Journal of Paediatric Dentistry, 16(1):38-40, (1991
212. Siebert & Trautna, Dept Expt Dentistry, Univ Wurzburg, Germany. “Z. Er-naehrungswiss. 24 (1985) pp. 54-66”. (Abstract:“Fluoride content of selectedhuman food, pet food and related materials”, Fluoride 19; No.3 (1986): pp. 152-153
213. Asanami S, Tanabe Y, Koga H, Takaesu, Y. - “Fluoride Contents in Tea andSakura Shrimp in Relation To Other Inorganic Constituents”, Shikwa Gakuho.1989; 89(8):1407-12
214. Dabeka WD, McKenzie AD. - Survey of lead, cadmium, fluoride, nickel, and cobaltin food composites and estimation of dietary intakes of these elements by Canadiansin 1986-1988. Journal of AOAC International. 1995; 78, 4: 897 909
215. Singer L, Ophaug R. - “Total Fluoride Intake Of Infants”, Pediatrics. 1979; 63:p.460
216. U.S. Dept. of Health, Education, and Welfare. Air Pollutants Affecting the Per-formance of Domestic Animals, Agricultural Handbook 1970; No. 380
217. Submission to Joint Oireachtas Committee on Health and Children on Fluoridationof Public Water Supplies in Ireland from Department of Health and Children,20/7/2000
218. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
100
DRAFT
219. Silva M, Reynolds EC, Fluoride Content Of Infant Formulae In Australia. Aus-tralian Den J., 1996; 41,1: 37-42
220. Mac Auley D. Water Fluoridation-Pollutant or Panacea, Irish Med J 2000; 93:165-168
221. Ibid
222. Silva M, Reynolds EC, Fluoride Content Of Infant Formulae In Australia. Aus-tralian Den J., 1996; 41,1: 37-42
223. Dr. Hardy Limeback, 12/10/2000
224. World Health Organisation (1994), Fluoride and Oral Health: Report of a WHOExpert Committee on Oral Health Status and Fluoride Use. WHO technical re-port, Series 846
225. Dr. Hardy Limeback, 12/10/2000
226. Fejerskov 0, Larsen MJ, Richards A and Baelum V., Dental Tissue Effects ofFluoride. Advances in Dental Research, 1994; 8(1): 15-31
227. Ismail Al, Fluoride Supplements: Current Effectiveness, side-effects and recom-mendations. Community Dental Oral Epidemiology, 1994, 22, 164-172
228. Padilla, 0. Davis MJ. Fluoride in the New Millennium. The New York StateDental Journal, Feb. 2001
229. Awad MA, Hargreaves, JA, Thompson GW, Dental Caries and Fluorosis in 7-9and 11-14 Year Old Children Who Received Fluoride Supplements from Birth, JCanadian Dental Association, 1991; 60:4: 318-322
230. Burt BA, The Case for Eliminating The Use of Dietary Fluoride SupplementsAmong Young Children, Fluoride, 1994 April, 27(2), 121. Abstract presented atthe Dietary Fluoride Supplement Conference, ADA Chicago, Jan. 31- Feb. 1, 1994
231. “Considerations re: Fluoride Supplementation”, approved by Resolution 2000.06,Canadian Dental Association Board of Governors, March 2000
232. Kiritsy MC, Levy SM, Warren JJ, Guha- Chowdhury N, Heilman JR, Marshall T,Assessing Fluoride Concentrations of Juices and Juice-Flavoured Drinks, Journalof American Dental Journal, 1996; Jul, 127 (7): 895-902
233. Levy SM, Kiritsy MC, Warren JJ, Sources of Fluoride Intake in Children, J ofPublic Health Dentistry, 1995, 55 (1), 39-52
234. Dr. Gerard Gavin, 20/7/200
235. Ibid
101
DRAFT
236. Advertisements. Colgate Herbal toothpaste. Aquafresh. Both broadcast on RTEand TV3. 237 Crest Toothpaste. Manufactured in United States. Proctor andGamble. Reverse side of tube
237. TV3 - 20/20 documentary. Hard To Swallow-The Water Fluoridation Debate.12/1/2001
238. -
239. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
240. Skotowski MC, Hunt RJ, and Levy SM, Risk Factors for Dental Fluorosis in Pae-diatric Dental Patients. Journal of Public Health Dentistry, 1995; 55: 154-159
241. British Fluoridation Society briefing. Dental Fluorosis in Perspective: The Good,The Bad and The Ugly. November 1997
242. Professor Denis 0 Mullane, 20/7/2000
243. Riordan PJ, Perceptions of Dental Fluorosis, Journal of Dental Research, 1993; 72(9): 1268-1274
244. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
245. Dr. Hardy Limeback, 12/10/2000
246. Mac Auley, D. Water Fluoridation-Pollutant or Panacea, Irish Med J. 2000; 93:165-168
247. Douglas, et al. Impact of Water Fluoridation on Dental Practices and Manpower.Journal Of American Dental Journal 1972; 84: 355-67
248. Department of Health, Hawkins House, Dublin. Fluoridation of Public WaterSupplies in Ireland, 12/4/2000
249. Dr. Maire 0 Connor. Promoting public health through fluoridation. Irish MedicalNews, 31/10/2000
250. Dr. Hardy Limeback, 12/10/2000
251. Chlebna-SokOl D(1), Czerwinski E(2), Bone structure assessment on radio-graphsof distal radial metaphysics in children with dental fluorosis, Fluoride, 1993; 26:1:37-44
252. Gavin, 20/7/2000
253. Fluorine and Fluorides. World health Organisation, Geneva, 1984: p152-15
102
DRAFT
254. Feyerskov 0, Ekstrand J, Burt BA. Fluoride in Dentistry. Munksgaard Textbook.1996; Chapter 8: p. 167
255. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
256. Limeback, 12/10/2000
257. Professor Dennis 0 Mullane, 20/7/2000
258. Guidelines for Drinking Water Quality, 2nd ed. Vol.2. Health criteria and othersupporting information. Geneva, World Health Organisation, 1996.pp. 231-237
259. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
260. Ibid. p. 82
261. Ibid. p. 83
262. Ibid. p 83
263. George Glasser, Investigative Journalist and Medical Writer presentation to theDail Joint Committee on Health and Children. 20/7/2000
264. Department of Health and Children. Submission to Joint Oireachtas Commit-tee on Health and Children on Fluoridation of Public Water Supplies in Ireland.20/7/2000
265. Micheal Martin, Minister of Health, Interview with Miriam O’Callaghan, Prime-time, 22/2/2000
266. Fluoride Free Water Ireland website: http://homepage.eircom.net/ fluoridefree/campaign update/hip fractures.h
267. Mac Auley, D. Water Fluoridation-Pollutant or Panacea, Irish Medical Journal.2000; 93:165-168
268. TV3 - 20/20 documentary. Hard To Swallow-The Water Fluoridation Debate.12/1/2001
269. Agency for Toxic Substances and Disease Registry (ATSDR) (1993). ToxicologicalProfile for Fluorides, Hydrogen Fluoride, and Fluorine (F). U.S. Department ofHealth & Human Services, Public Health Service. ATSDR/TP-91/17 p56-57
270. Mac Auley, D. Water Fluoridation-Pollutant or Panacea. Irish Medical Journal.2000; 93:165-168
271. Professor 0 Mullane, 20/7/2000
103
DRAFT
272. Hillier S, Cooper C, Kellingray S, Russell G, Hughes H and Coggon D. Fluoridein drinking water and risk of hip fracture in the UK: a case control study. TheLancet. 2000; Vol. 355: p265-269
273. Jones G, Riley M, Couper D and Dwyer T. Water fluoridation, bone mass andfracture: a quantitative overview of the literature. Australian and New ZealandJournal of Public Health. 1999; Vol.23: No.1: p34-40
274. Dr. Limeback, 12/10/2000
275. Danielson C, Lyon JL, Egger M, Goodenough GK, Hip fractures and fluoridationin Utah’s elderly population. JAMA 1992 Aug 12;268(6):746-
276. Jacobsen SJ, Goldberg J, Cooper C, Lockwood SA, The association between waterfluoridation and hip fracture among white women and men aged 65 years and older.A national ecologic study. Ann Epidemiol 1992 Sep;2(5):617-26
277. Wolinski, I et al (). Effects of fluoride on metabolism and mechanical propertiesof rat bone. Am. J. Physiol. 1972; 223: 46-50
278. Bohatyrrewicz, A (1999). Effects of Fluoride on Mechanical Properties of femoralBone in Growing Rats. Fluoride; 32 (2): 47-54
279. Sowers MF, Clark MK, Jannausch ML, Wallace RB, A prospective study of bonemineral content and fracture in communities with differential fluoride exposure.Am J Epidemiol 1991 Apr 1;133(7):649-60
280. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
281. Guidelines for Drinking Water Quality, 2nd ed. Vol. 1. Recommendations.Geneva, World Health Organisation, 1993.p.47
282. Trace Elements in Human and Animal Nutrition: Fifth Edition, Edited by WalterMertz, U.S. Dept. of Agriculture, Agriculture Research Service, Beltsville HumanNutrition Research Centre, Beltsville, Maryland, 1987, p.368
283. National Academy of Sciences. Health Effects of Ingested Fluoride. USA 1993:p59
284. Department of Health and Human Services. Review of Fluoride Benefits and Risks.Feb. 1991. p. 17
285. Department of Health (U.K.), Report on Health and Social Subjects 41. Dietaryreference Values for food, energy and nutrients for the United Kingdom. 8th im-pression, London: HMSO; and nutrients for the United Kingdom. 8th impression,London: HMSO; 1996: p189
104
DRAFT
286. Submission to Joint Oireachtas Committee on Health and Children on Fluoridationof Public Water Supplies in Ireland from Department of Health and Children,20/7/2000
287. Ibid
288. Guidelines for Drinking Water Quality, 2nd ed. Vol.2. Health criteria and othersupporting information. Geneva, World Health Organisation, 1996.pp. 231-237
289. World Health Organisation, Fluorides and Human Health, 1970 p 239
290. Guidelines for Drinking Water Quality, 2nd ed. Vol.2. Health criteria and othersupporting information. Geneva, World Health Organisation, 1996.pp. 231-237
291. Dr. Limeback, 12/10/2000
292. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
293. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
294. Taylor, A., Sodium Fluoride in the drinking water of mice. Dent. Dig.1954; 60:170
295. Taylor and Taylor, Effect of Sodium Fluoride on Tumour Growth, Proc. Soc.Exptl. Biol. & Med. 1965; 119:252
296. Yiamouyiannis JA, Burk D. Fluoridation of public water systems and the cancerdeath rate in humans. Presented at the 67th Annual Meeting of the AmericanSociety of Biologists and the 67th Annual Meeting of the American Society ofBiologists and Chemists and the American Society of Experimental Biologists.June 1976
297. Ministere de (’Environment, Gouvernment du Quebec. Les fluorures, la fluorura-tion, et la qualite de (’environment, 1979, pp. 103-104, 107-108, and 111. 1979,pp. 103-104, 107-108, and 111
298. National Toxicology Program [NTP] Toxicology and Carcinogenesis Studies ofSodium Fluoride in F344/N Rats and B6C3f1 Mice. Technical report Series No.393. NIH Publ. No 91 2848, (1990).. Mice. Technical report Series No. 393. NIHPubl. No 91 2848, (1990).. National Institute of Environmental Health Sciences,Research Triangle Park, N.C
299. Maurer, J.K. et al. Two Year Carcinogenicity Study of Sodium Fluoride in Rats.Journal, National Cancer Institute, 1990; 82: 1118-1126
300. Guidelines for Drinking Water Quality, 2nd ed. Vol.2. Health criteria and othersupporting information. Geneva, World Health Organisation, 1996.pp. 231-237.World Health Organisation, 1996.pp. 231-237
105
DRAFT
301. U.S. Public Health Service. Review of fluoride benefits and risks, report of the adhoc subcommittee on fluoride, Feb. 1991. Report on NTP study plus SEER dataon osteosarcoma fluoride, Feb. 1991. Report on NTP study plus SEER data onosteosarcoma in young men
302. Schlesinger, E. “Newburgh-Kingston caries-fluoride study.” JADA 1956; 52(March):290- 32
303. Ast, D., S. Finn, et al. “Newburgh-Kingston caries fluorine study; further analy-sis of dental findings including permanent and diciduous dentitions after 4 yearsof water fluoridation”.permanent and diciduous dentitions after 4 years of waterfluoridation“. J.Am.Dent.A. 1951; 42(February): 188-195
304. Mahoney Mc, Nasca PC, Burnett WS, Melius JM. Bone cancer incidence rates inNew York State: time trends and fluoridated drinking water. Am J Public Health1991; 81: 475-479. fluoridated drinking water. Am J Public Health 1991; 81:475-479
305. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
306. Cohn PD. A brief report on the association of drinking water fluoridation and theincidence of osteosarcoma among young males . N J Dept of Health, Trenton, NewJersey. Nov 8, 1992. young males . N J Dept of Health, Trenton, New Jersey. Nov8, 1992
307. Gelberg, K., E. Fitzgerald, et al. “Fluoride exposure and childhood osteosarcoma:a case- control study.” American Journal of Public Health. 1995; 85: 1678-1683
308. Tohyama E. Relationship between fluoride concentrations in drinking water andmortality from uterine cancer on Okinawa prefecture, Japan. J Epidemiology 1996;6: 184-191. Okinawa prefecture, Japan. J Epidemiology 1996; 6: 184-191
309. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
310. Shung-Guan CM, et al. The non-skeletal lesions of endemic fluorosis. Chinese Jof internal Medicine 1982; 21: 217-219
311. Hu YH. Direct damage on nervous system by Fluorosis. Compilation of FirstConference on Neuropsychiatric Diseases in Xinjian, 1982: 79-82. in Xinjian, 1982:79-82
312. Mullenix PJ, Denbesten PK, Schunior A, Kernan WJ. Neurotoxicity of sodiumfluoride in rats. Neurotoxicology Teratology, 1995; 17:169-177
313. Ross JF, Daston GP. Neurotoxicology and Teratology 1995; 17(6): 685-6. Letterto the editor
106
DRAFT
314. Forbes WF. Geochemical risk factors of mental functioning, based on the OntarioLongitudinal Study of Ageing (LSA). 6. The Effects of the associations of alu-minium and fluoride (LSA). 6. The Effects of the associations of aluminium andfluoride water concentrations and of pH with mental functioning, based on theresults from the LSA and from death certificates mentioning dementia. CanadianJournal on Ageing-Revue Canadienne Du Viellissement 1997; 16(1): 142-159
315. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
316. Isaacson R. Rat studies link brain cell damage with aluminium and fluoride inwater. State Univ. of New York, Binghampton, NY, Wall Street Journal articleby Marilyn Chase. 1982; Oct. 28: pB-6
317. Varner, J.A. et al (1998). Chronic Administration of Aluminium-Fluoride andSodium- Fluoride to Rats in Drinking Water: Alterations in Neuronal and Cere-brovascular Integrity. Brain Research 1998; 784: 284-298. Drinking Water: Al-terations in Neuronal and Cerebrovascular Integrity. Brain Research 1998; 784:284-298
318. American Dental Association. Health Media Watch: Study linking fluoride andAlzheimer’s under scrutiny. J Am Dent Assoc 1998;129:1216-8
319. Still CN, Kelleyp. On the incidence of primary degenerative dementia versus waterfluoride content in South Carolina. Neurotoxicology. 1980; 1(4):125-131
320. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
321. Li, Y., C. Liang, et al. “Effect of Long-Term Exposure to Fluoride in Drink-ing Water on Risks of Bone Fractures.” 1999 (unpublished). “Fractures.” 1999(unpublished)
322. Zhao, L., G. Liang, et al. “Effect of a high fluoride water supply on children’sintelligence.” Fluoride 1996; 29: 190-192
323. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
324. R.D. Masters, M.J. Coplan, B.T. Hone J.E. Dykes. Association of SilicofluorideTreated Water with Elevated Blood Lead. NeuroToxicology 2000; 21(6): 1091-1100
325. Mac Auley, D. Water Fluoridation-Pollutant or Panacea, Irish Medical Journal2000; 93:165-168,
326. Urbansky, ET, Schock MR. Can fluoridation affect Lead(II) in potable water?Hexafluorosilicate and fluoride Equilibria in aqueous solution. Intern. J. Environ.Studies, 2000, Vol. 20, pp 1-41.Equilibria in aqueous solution. Intern. J. Environ.Studies, 2000, Vol. 20, pp 1-41
107
DRAFT
327. Luke J. Fluoride Deposition in the Aged Human Pineal Gland. Caries Res 2001;35: 125- 12
328. Herman-Giddens, M.E. et al Secondary Sexual Characteristics and Menses inYoung Girls Seen in Office Practice: A Study for Pediatrics Research in OfficeSettings Network. Pediatrics, 1997; 99: p505-512. Study for Pediatrics Researchin Office Settings Network. Pediatrics, 1997; 99: p505-512
329. Schlesinger, E.). “Newburgh-Kingston caries-fluoride study.” JADA 1956; 52(March):290- 325
330. Needleman HL, Pueschel SM, RothmanKJ,. Fluoridation and the occurrence ofDown’s syndrome. N Engl J Med 1974; 291: 821-823
331. Rapaport I. Contribution a l’etude du mongolisme: role pathogenique du fluor.Bull Acad Natl Med (Paris) 1957; 143: 529-531
332. Rapaport I. Oligophrnic mongolienne et caries dentairs. Rev Stomatol Chir Max-illofac 1963; 46: 207-218
333. Erikson JD. Down’s syndrome, water fluoridation and maternal age. Teratology1980; 21: p177-180
334. Berry W. A study of the incidence of mongolism in relation to the fluoride contentof water. Am J of Ment Defic 1958; 62(4): 634-636
335. Erikson JD, Oakley GP, Flynt JW, Hay s. Water fluoridation and congenitalmalformation: No association. J Am Dent Assoc 1976; 76: 981
336. Kaminsky LS, Mahoney Mc, Leach J, Melius J, MillerMj. Fluoride: benefits andrisks of exposure. Crit rev Oral Biol Med 1990; 1: 261-281
337. Faculty of Public Health, Royal College of Physicians, Ireland. Water Fluoridationand Public Health, October 1999
338. Kaminsky LS, Mahoney Mc, Leach J, Melius J, MillerMj. Fluoride: benefits andrisks of exposure. Crit rev Oral Biol Med 1990; 1: 261-281
339. Guidelines for Drinking Water Quality, 2nd ed. Vol.2. Health criteria and othersupporting information. Geneva, World Health Organisation, 1996.pp. 231-237.World Health Organisation, 1996.pp. 231-237
340. Review of Fluoride Benefits and Risks, Department of Health & Human Services,February 1991 p. 5; see also: Health Effects of Ingested Fluoride, Subcommitteeon Health Effects of Health Effects of Ingested Fluoride, Subcommittee on HealthEffects of Ingested Fluoride, Committee on Toxicology, Board on EnvironmentalStudies and Toxicology, Commission on Life Sciences, National Research Council,August 1993 p 85
108
DRAFT
341. Agency for Toxic Substances and Disease Registry (ATSDR) (1993). ToxicologicalProfile for Fluorides, Hydrogen Fluoride, and Fluorine (F). U.S. Department ofHealth & Human Fluoride, and Fluorine (F). U.S. Department of Health & HumanServices, Public Health Service. ATSDR/TP-91/17
342. Ibid
343. Ibid
344. American Academy of Allergy. A statement on the question of allergy to flu-oride as used in the fluoridation of community water supplies. J Allergy ClinImmunol 1971;47(6):347-8. community water supplies. J Allergy Clin Immunol1971;47(6):347-8
345. Waldbott, G.L., Burgstahier, A.W. and McKinney, H.L. (1978). Fluoridation: TheGreat Dilemma. Coronado Press, Inc., Lawrence, Kansas, 1978 Inc., Lawrence,Kansas, 197
346. Waldbott GL. Urticaria due to fluoride. Acta Allergologica 1959; 13: 456-46
347. Waldbott GL. Allergic reactions to fluoride. Journal of Asthma Research 1964; 2:51-64
348. Waldbott GL. Fluoride in clinical medicine. International Archives of Allergy andApplied Immunology 1962: 20 (Suppl 1); 1-60
349. Moolenburgh H. Fluoride: The Freedom Fight. Mainstream Publishing, Edinburgh1987 pp 65-66, 146-14
350. Waldbott GL. Allergic reactions to fluoride. Journal of Asthma Research 1964; 2:51-6
351. Douglas TE. Fluoride dentifrice and stomatitis. Northwestern Medicine 56 107-139195
352. Safe Drinking Water Committee, National Research Council. Drinking water andhealth. National Academy of Sciences. Washington, DC; 1977. Sciences. Wash-ington, DC; 1977
353. Overton D, Chase H. Newburgh-Kingston caries fluorine study; paediatric aspectscurrent status. New York J Med. 1954; 54: 2452-2457
354. Rapaport I. Oligophrnic mongolienne et caries dentairs. Rev Stomatol Chir Max-illofac 1963; 46: 207-218
355. Schatz, A. Increased death rates in Chile associated with artificial fluoridation ofwater, with implications for other countries. Journal of Arts, Science, and Hu-manities 1976; 2: 1-17. other countries. Journal of Arts, Science, and Humanities1976; 2: 1-17
109
DRAFT
356. NHS CRD A systematic review of water fluoridation. York: NHS Centre forReviews and Dissemination. University of York, 200
357. Schatz, A. Increased death rates in Chile associated with artificial fluoridation ofwater, with implications for other countries. Journal of Arts, Science, and Hu-manities 1976; 2: 1-17. other countries. Journal of Arts, Science, and Humanities1976; 2: 1-17
358. American Dental Association website
http://www.ada.org/public/topics/fluoridelfacts-saf23-33.html#2
359. Bachinskii PP, Gutsalenko OA, Naryzhniuk ND, Sidora VD, Shliakhta Al -“Actionof the body fluorine of healthy persons and thyroidopathy patients on the functionof persons and thyroidopathy patients on the function of Hypophyseal thyroid thesystem” Probl Endokrinol 1985; 31(6): 25-9
360. Hillman D, Bolenbaugh DL, Convey EM - “Hypothyroidism and anemia relatedto fluoride in dairy cattle” J Dairy Sci 1979; 62(3): 416-23
361. Tokar’ VI, Savchenko ON - “Effect of inorganic fluorine compounds on the func-tional state of the pituitary-testis system” Probl Endokrinol (Mosk) 1977; 23(4):104-7
362. Zhao W, Zhu H, Yu Z, Aoki K, Misumi J, Zhang X -“Long-term Effects of VariousIodine and Fluorine Doses on the Thyroid and Fluorosis in Mice” Endocr Regul1998; 32(2):63-70. Thyroid and Fluorosis in Mice” Endocr Regul 1998; 32(2):63-70
363. Lin Fa-Fu, Aihaiti, Zhao Hong-Xin, Lin Jin, Jiang Ji-Yong, Maimaiti, and Aiken.The Relationship of a Low-Iodine and High-Fluoride Environment to SubclinicalCretinism in Xinjiang. Iodine High-Fluoride Environment to Subclinical Cretinismin Xinjiang. Iodine Deficiency Disorder Newsletter 1991 August Vol. 7 No.
364. Jooste PL, Weight MJ, Kriek JA, Louw AJ- “Endemic goitre in the absence ofiodine deficiency in schoolchildren of the Northern Cape Province of South Africa”Eur J Clin Nutr 1999; 53(1):8-12. National Research Programme for NutritionalIntervention, Medical Research Council, Tygerberg, South Africa.
365. Freni SC , Exposure to high fluoride concentrations in drinking water is associatedwith decreased birth rates. Journal of Toxicology and Environmental Health 1994;42: 109-12
366. Ibid
367. Chinoy NJ , Narayana MV. In vitro fluoride toxicity in human spermatozoa. Flu-oride 1994; 27: 231-232
368. Susheela AK, Jethanandani P. Circulating testosterone levels in skeletal fluorosispatients. J Toxicol Clin Toxicol 1996; 34: 183-9
110
DRAFT
369. Narayana MV, Chinoy NJ. Effect of fluoride on rat testicular steroidogenesis. Flu-oride 1994; 27: (Research Report 7), 17-12
370. Susheela AK, Kumar A. A study of the effect of high concentrations of fluorideon the reproductive organs of male rabbits, using light and scanning electron mi-croscopy. J. of Reproduction and Fertility 1991; 92: 353-360. rabbits, using lightand scanning electron microscopy. J. of Reproduction and Fertility 1991; 92: 353-360
371. Klein W, et al . DNA repair and environmental substances. Zeitschrift fur Ange-wandte Bader-und Klimaheilkunde . 1977; 24 (3): 218-223
372. Mohamed A, Chandler ME. Cytological effects of sodium fluoride on mice. Fluoride. 1982; 15 (3) 110-18
373. Jagiello G. Lin J-S. Sodium fluoride as potential mutagen in mammalian eggs.Archive Environmental Health. 1974; 29: 230-5
374. Holman RA. British Medical Journal. April 45, 1961
375. Department of Health & Human Services. Fluoride Benefits and Risks. February1991 p. 8
References
[1] National Research Council Committee on Fluoride in Drinking Water. Fluoride inDrinking Water: A Scientific Review of EPA’s Standards. The National AcademiesPress, 2006.
[2] Minutes. Dental consultative council. Technical report, Department of Health, Ire-land, 1951.
111